GOULD AND PYLE'S CYCLOPEDIA 
OF 
PRACTICAL MEDICINE AND SURGERY 
SCOTT 
VOLUME II. J TO Z GOULD AND PYLE'S 
CYCLOPEDIA OF PRACTICAL 
MEDICINE AND SURGERY 
WITH PARTICULAR REFERENCE TO DIAGNOSIS AND TREATMENT 
THIRD EDITION, REVISED AND ENLARGED 
VOLUME II. JABORANDI- ZOSTER 
By R. J. E. SCOTT, M. A., B. C. L., M. D., 
NEW YORK 
WITH SIX HUNDRED AND FIFTY-THREE ILLUSTRATIONS 
CONTRIBUTORS TO THIS AND PREVIOUS EDITIONS 
James M. Anders, M.D. 
Edward R. Baldwin, M.D. 
C. R. Bardeen, M.D. 
Lewellys F. Barker, M.D. 
John F. Binnie, C.M. 
Charles W. Bonney, M.D. 
Nathan E. Brill, M.D. 
Archibald Church, M.D. 
L. Pierce Clark, M.D. 
Solomon Solis-Cohen, M.D. 
Warren Coleman, M.D. 
W. M. Late Coplin, M.D. 
Nathan S. Davis, Jr., M.D. 
Theodore Diller, M.D. 
Charles Hunter Dunn, M.D. 
J. Clifton Edgar, M.D. 
Charles P. Emerson, M.D. 
Augustus A. Eshner, M.D. 
Francis A. Faught, M.D. 
B. A. Fedde, M.D. 
Virgil P. Gibney, M.D. 
R. Max Goepp, M.D. 
E. H. Goodman, M.D. 
George M. Gould, M.D. 
Charles Lyman Greene, M.D. 
W. A. Hardaway, M.D. 
H. F. Harris, M.D. 
John C. Hemmeter, M.D. 
Barton Cooke Hirst, M.D. 
Bayard Holmes, M.D. 
E. Fletcher Ingals, M.D. 
Abraham Jacobi, M.D. 
Allen A. Jones, M.D. 
William W. Keen, M.D. 
Howard S. Kinne, M.D. 
Alexander Lambert, M.D. 
Ernest Laplace, M.D. 
James Hendrie Lloyd, M.D. 
William H. G. Logan, M.D., D.D.S. 
William Palmer Lucas, M.D. 
L. S. McMurtry, M.D. 
G. Hudson Makuen, M.D. 
Matthew D. Mann, M.D. 
Henry 0. Marcy, M.D. 
Rudolph Matas, M.D. 
Joseph M. Mathews, M.D. 
John K. Mitchell, M.D. 
E. E. Montgomery, M.D. 
Harold N. Moyer, M.D. 
A. G. Nicholls, M.D. 
Albert J. Ochsner, M.D. 
A. H. Ohmann-Dusmesnil M.D. 
Sir William Osler, M.D. 
George E. Pfahler, M.D. 
Clemens F. von Pirquet, M.D. 
Walter L. Pyle, M.D. 
B. Alexander Randall, M.D. 
Joseph Ransohoff, M.D. 
William L. Rodman, M.D. 
R. C. Rosenberger, M.D. 
J. Torrance Rugh, M.D. 
Jay F. Schamberg, M.D. 
R. J. E. Scott, M.D. 
F. M. Shook, M.D. 
Joseph F. Siler, M.D. 
Richard Slee, M.D. 
Frederic E. Sondern, M.D. 
Edmond Souchon, M.D. 
Ward F. Sprenkel, M.D. 
Francis T. Stewart, M.D. 
Charles G. Stockton, M.D. 
John Madison Taylor, M.D. 
William S. Thayer, M.D. 
J. Ashburton Thompson, M.D. 
James Thorington, M.D. 
Martin B. Tinker, M.D. 
James Tyson, M.D. 
J. William White, M.D. 
Reynold W. Wilcox, M.D. 
Harvey W. Wiley, M.D. 
George Wilkins, M.D. 
Albert Woldert, M.D. 
Alfred C. Wood, M.D. 
Horatio C. Wood, M.D. 
James K. Young, M.D. 
P. BLAKISTON'S SON & CO., PHILADELPHIA Copyright, 1916, by P. Blakiston's Son & Co. 
THE MAFEE PRESS YORK PA JABORANDI 
JAUNDICE 
J 
JABORANDI.-See Pilocarpus. 
JACOB'S ULCER.-See Epithelioma. 
JACTITATION.-A restless and anxious tossing 
to and fro, from one posture to another; a symp- 
tom of conscious or unconscious distress observed 
in all severe mental affections. It is associated 
with certain severe febrile diseases, with severe 
pericarditis, or as a sequence of uterine or other 
hemorrhages. A restlessness amounting to j actita- 
tion may occur in those suffering from severe or 
long-continued pain. It must not be confounded 
with chorea, in which the absence of pain and of 
marked febrile disturbance, together with the his- 
tory of the patient, will establish a ready diagnosis. 
JALAP.-The dried tuberous root of Exogonium 
purga, a Mexican plant. It shoud contain not 
less than 8 percent of total resin, which is com- 
posed of two glucosids, jalapin, soft, soluble in 
ether, an convolvulin, which is hard, insoluble in 
e#her and the more active of the two. Dose, 5 to 
20 grains. 
Jalap is an active cathartic, producing co- 
pious and watery stools, with considerable tormina 
and tenesmus, also sometimes nausea. It is 
more drastic than senna and less irritant than 
gamboge, but in overdoses may produce dangerous 
hyper catharsis. 
Convolvulin in sufficient dose is an active irritant 
poison, producing gastroenteritis and narcotism. 
Its action as a purgative seems to be wholly local, 
as from its intravenous injection no catharsis 
results, yet it exerts little if any irritant action on 
the conjunctiva, nasal mucous membrane or skin. 
It is not eliminated in the urine or the feces, and 
is therefore probably destroyed in the system 
by oxidation. 
In olden times jalap and calomel were used 
together, in doses of 10 grains each, as a routine 
purgative prescription. Less ponderous doses 
are now considered equally efficient, and 1 grain 
of each agent, with the same quantity of extract 
of hyoscyamus as a corrective, may be used with 
advantage at the onset of fevers and inflammations. 
As the compound powder, it is much employed to 
produce free watery evacuations in ascites and 
anasarca. Being nearly tasteless, it is a useful 
cathartic for children, and may be administered 
in syrup of rhubarb (2 to 5 grains in 1/2 
ounce). As a vermifuge it is efficient as an ad- 
junct to more powerful agents, and is employed 
with calomel and santonin for the expulsion of 
lumbrici. Jalap is contraindicated in all inflam- 
matory conditions of the intestinal mucous mem- 
brane. 
Preparations.-Resina J., Resin of jalap, pre- 
pared from a tincture by precipitation by water. 
Is insoluble in water, soluble in alcohol. Dose, 
1 to 5 grains. It is an ingredient of pil. cathartic, 
comp, and pil. cathartic, vegetabiles. 
Pulvis J. Compositus, Pulvis purgans, has of 
jalap 35, potassium bitartrate 65, thoroughly 
mixed. Dose, 10 to 45 grains. 
JAMESTOWN WEED.-See Stramonium. 
JAUNDICE (Icterus).-Deposition of bile pig- 
ment in the tissues of the body. 
Varieties.-(1) Hepatogenous or obstructive 
jaundice; (2) hematogenous or nonobstructive 
jaundice. 
Hepatogenous Jaundice. 
Etiology.-(1) Obstruction by gall-stones or 
parasites; (2) catarrhal condition of bile-duct or 
duodenum; (3) stricture of gall-duct; (4) pressure 
from tumors in the neighboring organs (cancer 
of liver, pancreas, etc.); (5) altered blood-pressure 
in the vessels of liver, causing greater pressure in 
the smaller ducts than in blood-vessels. 
Symptoms and Clinical Course.-Deposition of 
the biliary pigments in the skin or conjuctivse, 
causing a distinct yellowness or bronzed hue. 
It is often first detected in the conjunctivae. The 
urine is of a dark amber or blackish color, staining 
the linen frequently, and with nitric acid shows 
the play of colors denoting the presence of biliary 
pigment. The pulse is sb w and full; the feces are 
light in color, on account of the absence of the bile 
pigment. Often the pigment may be detected in 
the perspiration, and may be so pronounced as 
to stain the bed-linen. Usually some form of 
skin-eruption supervenes, and it may keep the 
patient irritable on account of its itching character. 
The mental symptoms are quite marked, there 
being great dejection of spirits and despondency. 
The appetite is lost and nausea is almost con- 
stantly present. 
Diagnosis.-The yellowness of the skin and con- 
junctivae should be distinguished from the greenish 
appearance in chlorosis, most common in females 
under 20; and from Addison's disease, in which 
the pigment is darker and less uniform than in 
jaundice. Bile is present in the urine of jaun- 
diced patients from obstruction of the bile-ducts, 
while in Addison's disease it is absent. 
Hematogenous Jaundice. 
Etiology.-(1) It results from rapid destruction 
of the liver cells, as in hypertrophic cirrhosis of the 
liver and in acute yellow atrophy. (2) It may 
be brought about by toxic agents causing a rapid 
destruction of the red blood-cells, such as is seen 
in snake-poisoning, yellow fever, malarial hemo- 
globinuria, relapsing fever, arsenical or phos- 
phorus-posioning. 
Symptoms and Clinical Course.-The jaundice 
is not so marked as in the obstructive form. 
Guiteras has often called attention to the fact JAUNDICE 
JAWS, DISEASES 
that jaundice in the patient suffering with yellow 
fever can only be appreciated at a distance. 
In hematogenous jaundice the stools are gener- 
ally normal in color, pulse may be accentuated, 
and the skin does not itch. 
Prognosis depends upon the cause. 
Treatment is the same as in simple catarrhal 
jaundice. See Gall-bladder (Diseases). 
Jaundice of the New-born. 
(Icterus Neonatorum.) 
Etiology.-It results: (1) Physiologically from the 
destruction of large numbers of red blood-cells 
during the first few days after birth, or from 
severance of the placental circulation, permit- 
ting absorption from the bile capillaries; (2) 
pathologically, as in congenital absence of biliary 
ducts, syphilis, or septic poisoning. 
Treatment.-Usually medicines are not indi- 
cated. If bowels are constipated, castor oil (1 
dram) or an enema of soapsuds and lukewarm 
water may be used. A daily lukewarm bath 
should also be given to keep the skin active and 
for its stimulating effect. 
JAUNDICE, ACUTE FEBRILE.-See Weil's 
Disease. 
JAWS, DISEASES. 
Diseases of the Gums.-See Gums. 
Alveolar Abscess.-{q. v.). 
Epulis.-This term, though formerly employed 
to signify any tumor growing from the gums, is 
now usually restricted to the variety that was then 
distinguished as the fibrous or common epulis. An 
epulis consists principally of fibrous tissue, but may 
sometimes contain a few myeloid cells. It fre- 
quently appears to depend upon the irritation of 
a carious stump, and springs from the periodontal 
membrane lining an alveolus. Beginning as a 
swelling of the little tongue-like process of gum 
between the teeth, as it increases in size it ap- 
pears as a hard, fleshy, circumscribed, smooth 
or slightly lobulated elastic growth, covered by 
mucous membrane. When it has existed some 
time, ulceration of the surface may occur, and 
one or more teeth become loosened or fall out. 
Treatment.-It should be excised with bone- 
forceps or a small saw, care being taken to cut 
away a small piece of the bone beneath, as other- 
wise it is likely to return. When quite small it 
may be shaved off, a thin layer of the bone at its 
base gouged away, and the offending tooth or 
teeth removed. 
Myeloid sarcoma {myeloid epulis) is occasionally 
found on the gums as a rapidly growing vascular 
tumor of a purplish-red color and soft spongy con- 
sistency. It should be entirely removed with the 
underlying bone, as otherwise it will return. The 
hemorrhage during removal is generally free, and 
may require the actual cautery to restrain it. 
Epithelioma {malignant epulis) of the gums is 
rare. In the upper jaw it has a marked tendency 
to creep up into the antrum {creeping epithelioma) 
and to simulate caries or necrosis of the jaw. 
Complete excision, with removal of the upper jaw 
if the antrum is involved, should be undertaken if 
there is a fair chance of getting the whole of the dis- 
ease away and if the glands are not much in- 
volved. 
Inflammation and abscess of the antrum is gener- 
ally due to the irritation of the fang of a carious 
tooth. It is attended by deep-seated pain, fol- 
lowed by swelling, edema, heat, and redness of the 
cheek and lower eyelid, and, when very acute, by 
sharp constitutional disturbance. The pus may 
Simple Catarrhal Jaundice. 
Synonyms.-Inflammation of the common bile- 
duct, catarrh of the bile-duct, catarrhal hepatitis. 
Definition.-Jaundice resulting from a catarrhal 
condition of the biliary passages. 
Etiology.-(1) An infectious agent (undeter- 
mined) ; (2) catarrh of the duodenum, extending up 
the common bile-duct; (3) certain diseases, such 
as pneumonia, typhoid fever, etc. 
Pathology.-The mucous membrane of duode- 
num and bile-ducts is engorged with blood, the 
lumen of ducts being occluded by thick tenacious 
mucus. If of long standing, necrosis may be set 
up, with consequent formation of ulcers. 
Symptoms and Clinical Course.-Jaundice, as the 
name implies, is the predominant symptom. The 
onset may be ushered in by a sense of nausea, vomit- 
ing, dull frontal headache, mental hebetude, con- 
stipation, high-colored scanty urine, slow full pulse, 
and slight fever. Patients with catarrhal jaundice 
are fretful and lose all ambition; are careless of the 
future and most despondent. 
The duration is from 1 to 3 weeks. 
Diagnosis.-The occurrence of jaundice with- 
out pain, feeling of nausea, despondency, slow full 
pulse, and slight fever (101°) usually distinguishes 
the disease from other causes productive of jaun- 
dice. 
Prognosis is favorable. 
Treatment.-Rest in bed is demanded. The diet 
should be regulated, only allowing liquid foods, 
such as sweet milk, beef-juice or beef-broth, stewed 
fruits, and cooked vegetables. Usually there is a 
loathing of all food, and the appetite must be kept 
up by offering such palatable articles as agree best 
with the stomach and bowels. In the beginning it 
is advisable to administer fractional doses (1/4 
grain) of calomel every hour until 6 or 7 doses 
have been taken, followed by a saline purge, if 
necessary. Should the patient show a tendency 
to remain constipated, the bowels may be kept 
open with the solution of magnesium citrate or by 
means of salines. Probably the remedy most used 
is sodium phosphate in doses of 1 dram, taken 2 or 
3 times daily as a laxative. The effervescent salt 
is quite agreeable. Carlsbad salt (1 dram) may be 
taken for the same purpose, also the Hunyadi 
Janos and Saratoga mineral waters in sufficient 
quantity to produce 1 or 2 stools a day. In the 
more chronic cases lavage may be practised every 
2 or 3 days, the fluid containing about 1 grain of 
silver nitrate. High enemata, by means of the long 
rectal tube and fountain syringe, may at the same 
time be administered 2 or 3 times a week. A series 
of small blisters over the right hypochondrium 
may do good. See Gall-bladder (Diseases). JAWS, DISEASES 
JAWS, DISEASES 
overflow into the nose or escape by the side of a 
tooth; or, in other instances, may distend the cav- 
ity and cause the bony walls to bulge. 
The treatment consists in providing a free exit 
for the pus as soon as formed, either by removing 
the carious tooth, and perforating the antrum 
through the bottom of the alveolus, or, if the teeth 
are sound, by perforating the anterior wall within 
the mouth through the canine fossa. The cavity 
should then be kept clean by antiseptic lotions. 
Closure of the jaws is the term applied to a con- 
dition in which the lower jaw cannot be opened, at 
least not to any extent. It may be due to: (1) 
Spasm of the masseter muscle consequent upon 
the irritation attending the eruption of a wisdom- 
tooth for which there is not room; (2) cicatricial 
contraction following ulceration of the mucous 
membrane induced by cancrum oris, syphilis, 
lupus, the abuse of mercury, etc.; (3) ankylosis of 
the temporomaxillary joint; (4) hysteria. 
Treatment.-When dependent upon the eruption 
of a wisdom-tooth, the tooth itself, or, under some 
circumstances, the second molar, must be extracted. 
When dependent upon cicatricial contractions, the 
forcible opening of the mouth by a screw-gag and 
maintaining it open by a cork placed between the 
teeth will, in slight cases, suffice. In other in- 
stances division of the cicatricial bands, and sub- 
sequently keeping the jaws separated, is success- 
ful, although this proceeding does not appear to 
have been always successful. When the bands are 
very dense, or the closure depends upon ankylosis 
of the temporomaxillary joint, a new articulation 
must be made by dividing the ramus of the jaw and 
removing a wedge-shaped piece of bone in front of 
the cicatricial contractions. 
Necrosis of the Jaws.-Necrosis is more common, 
and, when it occurs, more extensive in the lower 
than in the upper jaw, a fact due in part to the 
poorer blood supply of the former, and in part to 
the predilection of necrosis for compact rather 
than for cancellous bone. Though the necrosis 
may affect the whole of the jaw, it is more often 
limited to the alveolar process or to the anterior 
wall. The teeth may loosen and fall out; but 
at times they retain their connection with the 
gums and remain in situ after the removal of the 
sequestrum. 
The causes of necrosis of the jaw, as of necrosis 
elsewhere, generally depend upon inflammation of 
the periosteum or bone, which in the case of the 
jaw appears especially to be induced by the fumes 
of phosphorus, the abuse of mercury, carious teeth 
in strumous subjects, syphilis, the exanthemata, 
cancrum oris, and, lastly, injury, as in extracting 
a tooth. Phosphorus-necrosis is generally believed 
only to affect the subjects of carious teeth, but 
some maintain that it is a local manifestation of a 
general phosphorus poisoning. It is much less 
common since the amorphous form of phosphorus 
has been used for making matches. The produc- 
tion of new bone in necrosis of the lower jaw is 
generally extensive. In the upper jaw new bone 
is not formed after complete removal. In phos- 
phorus-necrosis a characteristic pumice-like de- 
posit of new bone is formed. 
Symptoms.-Necrosis generally begins with 
severe pain and deep-seated swelling, which may 
at first be mistaken for toothache or alveolar 
abscess, followed by suppuration and bursting of 
the abscess, either in the mouth or externally on 
the face, and the formation of sinuses. The breath, 
as a rule, is horribly fetid, and there is sharp con- 
stitutional disturbance, which, in phosphorus- 
necrosis, is sometimes excessive, and may end in 
septicemia or pyemia. On probing the sinus, dead 
bone is detected. This sign will usually distin- 
guish necrosis from the creeping form of epithe- 
lioma, for which, especially in the upper jaw, it may 
be mistaken. 
Treatment.-The bone, as soon as loose, should 
be removed, if possible, through the mouth. In 
the meantime the parts should be kept aseptic by 
syringing with an antiseptic fluid or carbolic lotion, 
or by insufflation of iodoform, incisions being 
made through the periosteum to insure a free drain, 
or a respirator may be worn to neutralize the fetor. 
Internally, tonics and stimulants and nourishing 
diet should be given, and iodid of potassium if 
there is a syphilitic taint. 
Tumors of the upper jaw may be cystic or solid, 
and the latter innocent or malignant; while cysts 
may likewise occur in the malignant solid tumors. 
Cystic tumors may be produced: (1) In connec- 
tion with the fang of a carious tooth; (2) by an 
error in development of the enamel sac covering 
the crown of a tooth {dentigerous cysts'); and (3) by 
obstruction of a mucous follicle in the lining mem- 
brane of the antrum. These cysts usually contain 
a serous, gelatinous, or a brownish fluid, in which 
cholesterin is often found. The condition known 
as dropsy of the antrum, and formerly believed to 
depend merely upon an accumulation of fluid in 
that cavity owing to the occlusion of the opening 
into the nose, would appear to be due to one of 
these mucous cysts completely filling the antrum. 
Dentigerous cysts, which may also occur in the 
lower jaw, are due to an error in the development 
of the enamel sac, usually of the permanent teeth. 
They differ from the ordinary dental cyst, depend- 
ing upon the irritation of a decayed fang, in that 
in the latter the fang will generally be found pro- 
jecting into the cyst, whereas in the dentigerous 
variety the crown alone, which has not been cut, 
or in some cases the whole tooth, will be found in 
the cyst. 
Solid tumors may spring from the periosteum 
covering the exterior of the bone, or from the 
mucous or the periosteal lining of the antrum. 
They may have a fibrous, cartilaginous, osseous, 
myxomatous, adenomatous, sarcomatous, or car- 
cinomatous structure; but fibrous and sarcomat- 
ous tumors are the most common, while cartila- 
ginous are very rare. Ossification of the sarcomat- 
ous growths is of occasional occurrence. They 
may be closely simulated by tumors of a like 
diversity of structure growing from the malar bone, 
the sphenomaxillary fossa, or the base of the 
skull. 
Symptoms and Diagnosis.-Clinically, it is not 
always possible to determine the exact structure 
of these tumors, nor is it essential, the surgeon's JAWS, DISEASES 
JAWS, DISEASES 
aim being rather to distinguish the solid from the 
fluid, and the innocent from the malignant, and to 
make out their origin and present attachments. 
When the tumor, whether cystic or solid, innocent 
or malignant, begins in the antrum, it sooner or 
later fills that cavity, and then in its further growth 
causes the walls to bulge in various directions. 
Thus, the bulging of the anterior wall causes a 
swelling on the cheek; of the internal wall, an 
obstruction in the nose; of the inferior wall, a 
depression of the palate; and of the superior wall 
a protrusion of the eye. A rounded projection on 
the cheek, a sensation of fluctuation felt through 
the anterior wall of the antrum with the finger in 
the mouth, or an eggshell-like crackling produced 
by the yielding of the thinned and partially 
absorbed walls, the presence of a carious tooth or 
the absence of one of the teeth in the series (in the 
case of a dentigerous cyst), will point to the cystic 
nature of the swelling, and puncture with a trocar 
and cannula will clear up any doubt. Should the 
tumor be solid, it will probably be innocent if of 
slow growth and there is absence of pain and glan- 
dular enlargement, nonimplication of the skin, and 
noninfiltration of surrounding parts; but malignant 
if of rapid growth and there is severe pain, early 
escape through the walls of the antrum, implication 
of the skin, involvement of glands, and protrusion 
of a fungous mass in the mouth, nose, or on the 
cheek. In malignant disease, moreover, the 
patient will probably be either young, in the case 
of sarcoma, or advanced in life, in the case of car- 
cinoma; but if a small piece of the growth can be 
obtained, a microscopic examination will settle the 
point. When the growth springs from the malar 
bone, it may either project forward on the cheek 
or into the mouth between the cheek and the bone, 
and the bulging of the walls of the antrum will be 
absent. When it arises from the sphenomaxillary 
fossa or base of the skull, it will commonly project 
into the nasopharynx, where it may be detected by 
the finger or rhinoscope, while the whole maxillary 
bone will be pushed forward. It should not be 
forgotten, however, that tumors beginning in the 
antrum, especially the fibrous and sarcomatous, 
encroach upon the surrounding parts, and, con- 
versely, that the cavity of the antrum may be 
invaded by growths not primarily connected with 
it; so that when a tumor in this region has attained 
a large size, it may be impossible to determine its 
origin, or, indeed, the whole of its actual attach- 
ments. 
Treatment.-For cystic tumors, excision of a 
portion of the wall from within the mouth will 
generally suffice, if a free drain is subsequently 
insured. At times the thinned walls of the cyst 
may be crushed together by the fingers with 
advantage. When the cyst is associated with a 
solid growth, the latter may sometimes be scraped 
away, otherwise the upper jaw must be partially 
or completely removed. When the tumor is solid 
and of an innocent nature, and entirely confined to 
the antrum, it may be removed by excision of the 
superior maxilla; but, as a rule, no more of the bone 
should be taken away than is absolutely necessary, 
the orbital plate and hard palate being preserved 
if possible. When the tumor arises behind the 
bone, there is often great difficulty in getting it 
away, as its attachments may be more extensive 
than is imagined. If thought advisable to attempt 
its removal, this may be done by excising the 
superior maxilla and clearing away the growth; 
or the maxilla may be turned outward, the growth 
removed, and the bone replaced {Langenbeck's 
method). 
When the growth is malignant and confined to 
the antrum, the superior maxilla may also be 
excised; but when it has invaded the surrounding 
parts, it becomes not only a question whether it 
can be completely got away, but whether the 
immunity from its return will not be of too 
short duration for the patient to undergo the risk 
of the operation. 
Complete Excision of the Upper Jaw.-Having 
extracted the central incisor tooth on the diseased 
side, make an incision down to the bone in the 
direction shown by the dark line in the accompany- 
ing figure. Dissect back the flap thus marked 
out from the bone, securing the larger arteries 
as they are divided. Make a longitudinal inci- 
sion through the mucous membrane lining re- 
spectively the floor of the nose and the roof of 
the mouth as far back as the soft palate, and then 
a transverse one along the junction of the soft 
palate with the hard palate on the diseased side 
Now pass one blade of the 
long jaw-forceps into the 
mouth and the other into the 
nose, and divide the alveolar 
process and hard palate; cut 
through the nasal process of 
the superior maxilla, and then 
through the malar bone, carry- 
ing the forceps into the sphe- 
nomaxillary fissure. Seize 
the bone with lion-forceps, 
and wrench it away from its 
remaining attachments. The 
internal maxillary, or any 
other large artery, should be 
tied, and hemorrhage from 
smaller vessels restrained by plugging the wound 
with strips of iodoform gauze. When the bleed- 
ing has stopped, any growth that may remain 
should be cut away or destroyed with the actual 
cautery. Unite the edges of the wound with 
horsehair sutures and the lip with harelip pins. 
Healing occurs readily and with little deformity. 
An obturator with false teeth should subsequently 
be fitted to the mouth. 
Partial excision of the upper jaw usually con- 
sists in leaving the orbital plate, and is done by 
dividing with a keyhole saw the front wall of 
the antrum along the margin of the orbit, and 
completing the operation as above described. 
Resection of the upper jaw {Langenbeck's opera- 
tion) consists in turning the maxillary bone out- 
ward so as to get at a tumor behind it, and then 
replacing the bone. As the connections of the 
bone along its outer part are left intact, its vascular 
supply is not completely cut off, and it soon forms 
fresh adhesions when placed back in position. 
Lines of Incision 
for Removal of Up- 
per and Lower Jaws 
-(Walsham.) JAWS, DISEASES 
JAWS, INJURIES 
Tumors of the lower jaw, like those of the upper, 
may be cystic or solid, innocent or malignant. 
Cystic tumors, as in the upper jaw, may be de- 
veloped in connection with an uncut tooth (dentig- 
erous cyst) or around the fang of a decayed tooth. 
They are then unilocular. Multilocular cystic tumors 
have a marked predilection for the lower jaw. 
They are probably due to invasion of the jaw by 
epithelium from the gum. The epithelial masses 
undergo degeneration, leading to cysts, often of 
considerable size. These tumors grow very 
slowly, and may gradually destroy the whole 
bone, reducing it to a mere shell; but if completely 
removed, do not recur locally. They never affect 
the glands or become disseminated. 
The solid tumors may grow from the periosteum 
covering either the outer or the buccal aspect of 
the jaw, or from the interior of the bone, which 
they then expand around them. The osseous 
tumors usually take the form of exostoses, and are 
not uncommon about the angle of the jaw. The 
more regular shape of the lower jaw, its compact 
structure, the absence of a cavity like the antrum, 
its more isolated condition, and the absence of sur- 
rounding cavities like the nose, orbit, and spheno- 
maxillary fossa, make the diagnosis of tumors 
in it more easy. The signs are similar to those of 
tumors of the upper jaw. 
Treatment.-Cystic tumors are best treated 
by free incision of a portion of their wall. In the 
case of the multilocular cysts the whole or part of 
the jaw may be removed. In excising solid in- 
nocent tumors no more of the bone should be 
sacrificed than is necessary to extirpate the disease; 
and such removal, when possible, should be done 
from within the mouth. Myeloid growths spring- 
ing from the interior of bone may often be enu- 
cleated, and not recur for many years, or not at all. 
When the tumor is large and encroaches upon the 
ramus, the affected half of the j aw, or, if both hal ves 
are affected, the whole jaw should be removed by 
disarticulation, as if the ramus is merely sawed 
across, leaving the coronoid process and condyle; 
these are apt to be drawn forward by the temporal 
and external pterygoid muscles and prove a con- 
stant source of annoyance. When the growth is 
malignant or of large size, and the skin and neigh- 
boring soft parts are implicated and the glands 
extensively involved, no operation, as a rule, is 
admissible. Cysts developed in connection with 
solid growths may be laid open and the tumor 
scraped away, or part or the whole of the jaw, if the 
growth is malignant, may be removed. 
Excision of the Lower Jaw.-Having extracted 
the central or the lateral incisor tooth, make an 
incision down to the bone (in the way shown in 
the black line in the accompanying figure) through 
the lower lip, along the lower border of the jaw, and 
thence up the ramus, nearly but not quite to the 
lobule of the ear to avoid the facial nerve, tying 
both ends of the facial artery as it is cut. Dissect 
up the flap thus formed from the bone, and divide 
the bone with saw and forceps opposite to where 
the tooth has been extracted. Seize the bone with 
the lion-forceps, drawing it outward and upward, 
and divide the soft tissue on the inner surface 
with a narrow-bladed scalpel, keeping close to the 
bone to avoid the gustatory nerve and the sub- 
maxillary gland. The origin of the geniohyo- 
glossus should be spared, if possible, as otherwise 
the tongue tends to fall backward, and has before 
now caused suffocation. If this muscle must be 
divided, pull the tongue forward by a ligature 
through its tip. Next separate the internal 
pterygoid, depress the jaw, and divide the tempo- 
ral muscle at its insertion into the coronoid process. 
Open the articulation from the front, divide the 
external pterygoid, and carry the knife beyond the 
condyle, taking care not to rotate the jaw outward 
lest the internal maxillary artery be stretched 
round the neck of the condyle and be thus torn or 
divided (Walsham). 
JAWS, INJURIES.-Dislocation of the jaw is 
possible only in the forward direction over the 
eminentia articularis. It is usually bilateral, al- 
though occasionally unilateral and sometimes con- 
genital. The bilateral dislocation is usually 
brought about by yawning or laughing, or is 
caused by straining the jaws apart, as in taking 
too large a bite of fruit. 
Symptoms.-Both condyles are advanced be- 
tween the surface of the temporal bone and zygo- 
matic arch; the mouth is open, and the patient is 
not able to shut it by pressure made on the chin; 
the lower teeth are on a line anterior to the upper; 
the appearance is that of a person yawning; 
Dislocation of the Lower Jaw. 
the pain is severe; the saliva is increased and 
dribbles from the mouth. If the lower jaw is 
partially dislocated, one condyloid process only 
advances, while the other remains in the articular 
cavity. 
Treatment.-To reduce the luxation the patient 
is seated in a chair with the head against the back 
of the chair or the body of an assistant. Standing 
in front of the patient, the operator, with thumbs 
well wrapped to protect them from the teeth, places 
them upon the last molar teeth and grasps the 
chin with the free fingers. Pressure is made down- 
ward and backward, and as soon as the condyle 
is loosened, the jaw is closed by pushing it over 
the condyle and pressing up the chin, using the 
thumbs as levers. Failing in this, wedges may be 
placed between the teeth and the chin pushed up 
by the hand or a tourniquet around the head JAWS, INJURIES 
JOINTS, DISEASES 
and chin. In unilateral displacement the wedge 
is to be used only on the dislocated side. After 
reduction, a bandage, preferably a Barton band- 
age, should be applied for over two weeks, being 
changed daily. The use of a liquid diet is advised 
for 3 weeks after dislocation. 
Fracture of the lower jaw is most common 
through the mental foramen: i. e., near the canine 
tooth. Occasionally it is through the neck of the 
ramus, or the coronoid process may be broken off. 
Fractures of this bone are nearly always compound. 
The fractured parts are to be adjusted, the loose 
and detached teeth pushed back, and the mouth 
rinsed with hot water to cleanse it and check 
hemorrhage. It may be necessary to compress 
the carotid artery to control the hemorrhage. 
A pad of lint should be placed under the broken 
parts and a four-tailed bandage applied, the ends 
crossing each other as they leave the symphysis, 
the two upper ends being tied at the nape and the 
two lower over the vertex of the head. A splint may 
be made out of card-board, soaked and applied to 
the broken jaw, being shaped to the symphysis and 
body. It should be lined with lint and held by a 
bandage, as a four-tailed bandage. Felt or gutta- 
percha may be molded to tho parts and held by a 
Gibson or Barton bandage. The teeth may be 
fastened with wire, the fragments themselves be 
wired together, or an interdental splint employed. 
Gibson bandage. It may be necessary to apply 
fine wire to the teeth, if displacement continues; 
or an interdental splint composed of gutta-percha 
may be used. Loosened teeth must be- pressed 
into their places. 
Should the nasal process be broken, a director 
should be applied through the nose to elevate any 
depression that may exist. 
Fracture of the Zygomatic Arch.-This accident 
is rare, and is produced by direct violence, usually 
occurring on the temporal side of the suture. 
The signs of this fracture are an irregular pro- 
jection or depression of the fragments, with rapid 
swelling of the parts. The displacement will occur 
either outward or inward. There will be neither 
motion nor crepitus. 
Treatment.-Should there be no displacement, 
apply an anodyne lotion and keep the parts quiet 
with a Gibson or Barton roller. If there is out- 
ward displacement, the fragments may be ad- 
justed by pressure on the projecting angle, after- 
ward applying a soothing lotion. If the displace- 
ment is occasioned by depression of the malar 
bone, it will be adjusted by restoration of that 
bone to its proper position, which requires extensive 
manipulation. The question of surgical inter- 
ference must depend upon the urgency of the 
symptoms. 
JERK.-A sudden muscular movement. A 
jerk produced by a sudden or quick stroke over a 
tendon or region gives an indication of the innerva- 
tion of a part. This is commonly seen at the knee, 
and here is known as the knee-jerk. The contrac- 
tion of the quadriceps femoris is then obtained. 
The legs are crossed one over the other and a sharp 
blow is made by the edge of the hand or some 
moderately wide instrument upon the patellar 
tendon just below the patella. The knee-jerk is 
usually absent in advanced locomotor ataxia, in 
diseases of the anterior gray cornua, in infantile 
paralysis, in the late stages of pseudohypertrophic 
paralysis, and often in meningitis, in diphtheria, 
and in diabetes. 
The jaw-jerk, or chin-jerk, is a contraction of the 
muscles of mastication produced by a stroke on the 
lower jaw or chin when the mouth is opened. It 
may be obtained in health, but when marked, is 
indicative of extensive cerebral lesion, such as 
multiple sclerosis or general paralysis. 
The wrist-jerk is obtained by a stroke upon the 
tendon of the extensor indicis or extensor ossis 
metacarpi pollicis, when they are made prominent 
by passive extension of the supine hand of the 
patient in that of the examiner. It may occur in 
health. 
The elbow-jerk, or triceps-jerk, is obtained by 
striking the triceps tendon while the arm is sup- 
ported and the forearm allowed to hang loosely 
downward parallel with the body. 
See Reflexes. 
JOINTS, DISEASES.-Diseases of the joints 
should be divided into acute and chronic. 
Dental Splint Applied -(Spencer and Gask.) 
Liquid food is to be given, and the mouth washed 
frequently. Dressings may be changed every 
second day. Union is usually complete in 5 weeks. 
Fractures of the Upper Jaw.-The superior 
maxilla is seldom broken, unless great and direct 
violence has been employed; its fracture is gener- 
ally accompanied by an external wound, as in gun- 
shot injuries or a kick from a horse. The fracture 
is often comminuted and is sometimes attended 
by concussion of the brain, or by fracture of other 
bones of the face; it is often produced by force 
transmitted from the malar bone, the latter 
remaining sound. The superior maxilla possesses 
extraordinary reparative powers. 
Treatment.-Preserve and replace all fragments 
and splinters, the tendency to heal being very 
great. The patient must avoid chewing any hard 
substances until the detached fragment has be- 
come attached to the bone. When the alveolar 
process is broken into two or more fragments, the 
pieces must be pressed into place and the jaws 
closed, so that the lower jaw may serve as a sup- 
port. To maintain apposition apply a Barton or 
Acute Joint-diseases. 
Simple Synovitis with Effusion.-Acute serous 
synovitis is the commonest form of joint-disease. JOINTS, DISEASES 
JOINTS, DISEASES 
As a rule, ft is the result of a contusion or cold, but 
may arise without any known cause. It may be 
caused by the infectious fevers, gout, rheumatism, 
gonorrhea, or syphilis. In point, of frequency the 
joints involved are the knee, the elbow, and the 
ankle. Among the joints less frequently involved 
are the hip, the shoulder, and the small joints of 
the extremities. The pathology of the disease is 
limited to changes in the synovial membrane, in 
which the usual manifestations of irritation and 
inflammation develop according to the cause pro- 
ducing the disease. 
The result is an intraarticular effusion, serous or 
hemorrhagic. From the admixture of lymph floc- 
culi the effusion has a tendency to become turbid. 
When this effect is the result of an irritation, such 
as is produced by a trauma, the presence of a blood- 
clot, the pinching of the synovial folds, or irrita- 
tion from toxic causes, such as occur in gout and in 
some cases of gonorrhea, there is a congestion of 
the synovial membrane, injection of the vessels, 
with the entire surface reddened, particularly about 
the line of attachment to the articular cartilages. 
The cartilages undergo no change, and by their 
pearliness are therefore in strong contrast to the 
reddened synovial surfaces. From the synovial 
membranes there is effused at first an increased 
quantity of synovia, and soon the exudate becomes 
closely allied to the serous effusion found elsewhere. 
Clear at first, it has a tendency to become turbid 
from the admixture of disintegrated epithelial cells 
and of leukocytes. The turbidity is often in- 
creased by the presence of blood discs, from minute 
hemorrhages into the joint-cavity. Within the 
exuded fluid flocculi of fibrin, in greater or less 
abundance, are usually found. These may be at- 
tached to the synovial fringes and to the more de- 
pendent portions of the joint, or they may be 
floating about in the free exudate. 
In mild cases of synovitis the condition de- 
scribed lasts from a week to ten days, when, by the 
gradual absorption of the exudate and the return 
of the distended vessels to their natural condition, 
the joint resumes its normal appearance and func- 
tion. In other cases absorption goes on very slowly, 
or it may altogether fail to take place, under which 
circumstances there is established the condition 
known as hydrarthrosis, the chief feature of which 
is the effusion into the joint. 
Simple Purulent Synovitis.-In less favorable 
cases or in consequence of improper management 
the exudation increases often to enormous propor- 
tions. Its character may also change; turbid at 
first, from the admixture of few cellular ele- 
ments, these increase until the exudate assumes a 
purulent character. The rapidity with which the 
effusion becomes purulent is at times so great that 
the synovitis in these cases seems to be purulent 
from the beginning. Except from the latter, the 
condition of the joint-interior does not vary at 
first in the simple purulent form of synovitis from 
the serous. 
Particularly in children, as Volkmann and Krause 
have shown, there may be a purulent effusion 
into the joint without destruction of the articular 
surfaces or permanent impairment of synovial 
membrane, joint capsule, or ligaments, provided 
spontaneous perforation occurs or an early outlet 
is made for the discharge. 
Dry Synovitis.-In certain cases of acute syno- 
vitis the fluid exuded may be very small in quan- 
tity or altogether absent. In proportion, the 
flakes of fibrin are greatly increased, until they 
may appear as a continuous layer covering the 
articular surfaces and forming a deposit of varying 
thickness on the synovial membrane and cartilages. 
The fibrin thus thrown out shows remarkable 
tendency toward organization. The smooth, 
glistening character of the serous surfaces is lost. 
In its place there are masses of fibrin, often un- 
evenly disposed, and by joint-movement often 
drawn into shreds of unequal length and adherent 
at one or both ends. If ankylosis does not occur, 
these shreds may speedily become detached and 
present themselves in the form of many small 
bodies, the size of a pea or bean, round or ovoid, 
and consisting of concentric rings of fibrin (rice 
bodies). In other cases the joint surfaces are 
speedily welded together by the organization of the 
exuded lymph. Ankylosis may sometimes follow 
an acute dry synovitis with remarkable rapidity. 
Symptoms and Diagnosis of Acute Synovitis.- 
The superficial position of most of the joints facili- 
tates the recognition of a simple, synovitis. Ex- 
cept in the joints deeply seated, like the shoulder 
and the hip, the four cardinal symptoms of inflam- 
mation can be easily recognized. In the latter 
joints only are we called upon to look to other than 
the characteristic symptoms for recognition of the 
condition. As is noted in the symptomatology of 
joint injuries, the patient first complains of pain, 
which, as a rule, is proportionate to the rapidity 
of the joint distention with fluid. Generally the 
pain is complained of in the joint itself. Only in 
exceptional cases, as in the hip, is it felt in a part 
far removed. With the pain there is associated 
more or less tenderness, often felt at one or more 
points along the articular line rather than over the 
entire area. In cases of traumatic origin the rea- 
son for this is apparent. In other cases Volk- 
mann has ascribed these special points of tender- 
ness to the deposit beneath them of fibrinous 
material. It is more probable, however, that 
these special points of tenderness correspond to 
the attachment of ligaments or duplicatures of the 
synovial membrane, which are stretched by un- 
equal tension of the effusion in the joint when 
pressure is made over them. When pain is not 
complained of when the limb is at rest, it will 
often be found to be very severe when any effort 
at motion, voluntary or passive, is made. The 
swelling is the most marked feature of a simple 
synovitis. Often within 24 or 48 hours it is suffi- 
ciently developed to have effaced all the normal 
outlines of the joint. 
The development of an acute synovitis is very 
frequently, although not always, associated with 
definite change in the position of the limb. For 
the most part one midway between flexion and 
extension is assumed, and maintained throughout 
the entire course of the disease. The knee 
becomes flexed upon the thigh, the foot becomes JOINTS, DISEASES 
JOINTS, DISEASES 
placed in the position of talipes equinus, the hip 
becomes flexed and abducted. When the shoul- 
der is involved, the arm is held close to the side of 
the body; in disease of the elbow the forearm is 
extended at an angle of 140 degrees; in disease of 
the wrist there is a slight drop, the fingers are 
maintained almost in extension, and the hand 
somewhat flexed on the forearm. The assump- 
tion of these positions has been accounted for 
through the fact that by them an equal pressure 
on different parts of the joint surface is secured, 
since they are positions taken by the joints when 
injected experimentally. This explanation does 
not obtain in cases of synovitis, since in some of 
great distention with serous fluid no faulty position 
is assumed. In every case of purulent synovitis 
this tendency to contracture makes itself apparent 
early, as it does also in cases of tubercular disease, 
to be hereafter considered. It is exceedingly 
probable, therefore, that the contracture is a fixed 
phenomenon, manifested only when, from the 
nature of the disease, prolonged fixation in the 
position in which extensors and flexors are equally 
favored is to be maintained for a long time. 
The symptoms heretofore considered are far 
more important than the remaining cardinal 
symptoms of redness and heat. In simple serous 
synovitis redness, as a rule, is altogether absent. 
In the purulent form it is present only when 
preparations are making toward spontaneous 
perforation. When synovitis is the result of 
joint contusion, the reaction following periarticu- 
lar injury is often causative of a redness far in 
excess of that which follows the synovitis alone. 
In joints superficially placed, like the elbow, the 
knee, and the wrist, a local elevation of tem- 
perature of from 1 to 2 degrees may usually be 
recognized. 
In cases of suppurative synovitis the general 
symptoms reflect the greater gravity of the local 
condition. With the systemic absorption of the 
products of inflammation, the usual accompani- 
ments of toxemia, chills and continuous fever, 
coating of the tongue, and anorexia are found. 
In the dry form of synovitis many of the local 
symptoms of the serous and purulent varieties 
are absent. Pain and tenderness are often very 
marked, and out of all proportion to the swelling, 
which, as a rule, is slight. In these cases the ten- 
dency to faulty position is very early developed. 
When efforts at motion are made, crepitus is felt. 
Movements of the patella upon the front of the 
femoral condyles may likewise cause such joint 
crepitus. When the latter is insufficient to be 
felt, it is distinctly audible when the ear is placed 
over the joint and the articular surfaces are moved 
upon each other. Passive movements are more 
painful than in the synovitis with effusion, and the 
pain associated therewith increases with the 
tendency to the formation of adhesions. The 
latter may form as early as the first week, and be 
firm enough to demand the anesthetizing of the 
patient for their severance and the correction of 
the concomitant deformity. The general symp- 
toms in cases of acute dry synovitis are often out 
of proportion to the severity of the local condition. 
Arthritis is inflammation not only of'the syno- 
vial membrane, but of all the structures of a joint. 
It may be acute or chronic and is due to trau- 
matism, extension by contiguity of tissue, nervous 
influence, or injection by way of the blood as, for 
instance, infectious fevers (scarlet fever, variola, 
measles, typhoid fever, pneumonia, erysipelas), 
gonorrhea, syphilis, gout, tuberculosis, pyemia. 
Acute infective arthritis is due to pathogenic 
organisms. If suppuration occurs, in addition 
to the synovial lining, the cartilages participate 
in the morbid process. They lose their pearly 
hue and assume a reddish or even blue tinge. 
Blood-vessels appear within them, and absorption, 
often in patches, takes place, the subjacent 
bone thereby becoming exposed. Shreds of 
cartilage are often raised in areas, become necrotic, 
and are thrown off into the joint cavity. The 
ligaments become softened and permeated by 
small purulent foci; the joint becomes loosened and 
devoid of function. 
Displacements of the articular ends of the bones 
are therefore of early and frequent occurrence. 
Caries of the articular ends, extending for a greater 
or less distance into the epiphyses, results. The 
periarticular structures, bursae, and tendon sheaths 
take part in the suppurative process. Abscesses 
communicating with the joint occur and develop 
in different places. They are often far removed 
from the part primarily involved. Unless ade- 
quate treatment is instituted, the destruction of 
the joint invariably follows. If the limb is saved, 
the suppuration gradually subsides through the 
drainage given by fistulous formations or by sur- 
gical treatment. The joint cavity is almost al- 
ways obliterated. Ankylosis, fibrous or bony, is 
an almost inevitable result. 
The general symptoms of acute suppurative 
arthritis are proportionate to the severity of the 
local condition. Almost from the beginning 
the temperature rises from 3 to 5 degrees, and 
continues, with morning remissions, until vent 
is given to the inflammatory products or until 
death ensues from exhaustion. The fatality of 
this condition will be referred to in the section 
on penetrating wounds of the joints. See Joints 
(Injuries). 
Gouty arthritis is but a manifestation of the 
general condition. It is serous, limited usually 
to the metatarsophalangeal joint of the left foot, 
associated with extensive periarticular swelling 
and redness. Through the soft parts, after the 
subsidence of the acute disease, nodules of calcare- 
ous deposit can often be felt within and about 
the joint structures, more or less defacing the 
joint outline and limiting motion to a varying 
degree. The subjective symptoms of pain and 
of tenderness are in excess of the local underly- 
ing conditions. Both rheumatic and gouty syno- 
vitis are further characterized by their ten- 
dency to become subacute, and even chronic. 
The structural changes involve the cartilage, 
ligaments, and periarticular structures. Both of 
these forms of synovitis, but particularly the 
gouty, are characterized further by their tendency 
to recur. JOINTS, DISEASES 
JOINTS, DISEASES 
Gonorrheal arthritis is due to infection from the 
urethra or rarely from the conjunctiva in gonor- 
rheal ophthalmia. Generally it arises during 
the subsiding stages of the primary gonorrheal 
urethritis or in chronic cases. According to 
symptoms it may be divided into seven varieties, 
as suggested by R. P. Howard of Montreal: 
1. The simple arthralgic form, in which there is 
pain, without fever, with a tendency to travel from 
joint to joint. 
2. Rheumatoid gonorrheal arthritis, very similar 
to acute inflammatory rheumatism. In addition 
to the local symptoms of rheumatism, fever is pres- 
ent and frequently polyarthritic involvement 
out of proportion to the severity of other symp- 
toms (maximum 102° F.). 
3. Acute gonorrheal monarthritis, in one joint 
only, characterized by severe pain and swelling 
and moderate fever. The knee-joint is most com- 
monly attacked. Next in order follow the ankle, 
shoulder, elbow and wrist. Suppuration is rare. 
4. Chronic gonorrheal arthritis, without or with 
effusion (chronic hydroarthrosis). Rarely sup- 
puration takes place and pus is found in the joint 
cavity. There is generally slight rise of tempera- 
ture. 
5. The periarthritic variety, characterized by 
involvement of the periarthritic tissues, including 
the periosteum, capsule, ligaments, tendons, 
and adjacent fibrous structures, without the 
joint cavity itself being attacked. 
6. A variety that attacks fibrous tissue not 
connected with joints, as the plantar fascia, the 
sclerotic coat of the eye and iris, the pericardium 
and endocardium. 
7. The septicemic form, characterized, in addi- 
tion to the arthritis, by symptoms of general sepsis 
and endocarditis. 
The diagnosis of gonorrheal arthritis is not diffi- 
cult when the presence of the primary disease is 
known. From ordinary rheumatism it may be dif- 
ferentiated by its being monoarticular as a rule, 
the ankle, knee, and wrist being most frequently 
involved; by the low range of temperature, the 
absence of the profuse sweating and heavily loaded 
urine characteristic of rheumatic disease. Gonor- 
rheal rheumatism, as it is too often misnamed, as 
a rule retrogrades slowly toward recovery. Often, 
however, the effusion becomes permanent. In 
other cases the plastic material thrown out tends 
toward the formation of fibrous ankylosis. Most 
ankyloses of the knee that are not the result of 
tuberculosis or trauma in young male subjects owe 
their origin to gonorrheal infection. Complica- 
tions of general infection, such as endocarditis, 
may occur. Syphilis very rarely produces pri- 
mary acute articular disease. Occasionally during 
the eruptive stage joint pains are complained of. 
Serous effusions do not occur frequently, and are 
almost altogether limited to the knee. Ordinarily, 
the joint complications of syphilis are second- 
ary to gummatous deposits in the epiphyses. In 
the hereditary syphilis of early life multiple 
joint lesions of this nature are often seen. In 
doubtful cases aspiration should be resorted to 
and a study made of the fluid secured. 
Treatment.-The treatment of acute arthritis 
has a fourfold object: (1) The limitation of inflam- 
matory process; (2) the removal of the products of 
inflammation; (3) the prevention of deformity; 
(4) the restoration of full physiologic function. 
Position and rest are important elements of 
treatment of inflammation of the larger joints. 
The patient should be put to bed and the limb 
suspended at nearly a right angle. Suspension 
alone often cuts short an attack of synovitis. 
When possible, a proper splint should be applied, 
and circulation controlled by an elastic bandage. 
Applications of ice or astrigent lotions of acetate of 
lead and tincture of opium or the chlorid of am- 
monium will be of service. 
To remove the products of inflammation prep- 
arations of iodin, of mercury, and of lead may 
be used. Blisters are often very efficacious, after 
the acute stage has passed off. Fixation of the 
joint in plaster-of-Paris, starch, or liquid glass 
is often very serviceable. Such fixation should not 
be continued for more than 2 weeks at a time. 
Massage and elastic compression will likewise 
prove efficient in removing joint effusions. When 
the latter resist these measures, aspiration of the 
joint should be practised. While all of the fluid 
cannot be removed by aspiration, the removal 
of only a part will relieve the intraarticular ten- 
sion sufficiently to permit the function of absorp- 
tion by the synovial membranes. When one or 
two aspirations have failed, a permanent cure 
can be generally secured by injecting into the 
joint cavity 2 or 3 drams of a 5 percent solution 
of carbolic acid. Bier's hyperemic treatment 
(q. t.) has been applied with benefit especially 
in acute gonorrheal arthritis. 
In suppurative arthritis efficient drainage must 
be secured at the earliest possible moment. With- 
out it, joint function cannot be saved. Arthrot- 
omy-i. e., the removal of the entire synovial 
membrane-often proves a conservative measure. 
Deformity is to be prevented by giving the limb 
a proper position from the onset of the disease, 
and one, which, in the event of ankylosis, would 
leave it most useful. 
Restoration of function is the most difficult 
achievement in the treatment of acute joint- 
diseases. It can be met only by properly con- 
ducted passive movements instituted as soon as 
the height of inflammation has been thoroughly 
passed. 
In gonorrheal arthritis in addition to combating 
the urethritis, absolute rest of the joints involved, 
and inunctions of colloidal silver ointment (1/2 
ounce into each joint involved three times a 
day) are recommended, ichthyol ointment (10 
percent) being advised in the interval between 
the inunctions. Reports of the use of antigon- 
ococcus serum and vaccine therapy (q. v.) are 
encouraging. Antistreptococcus serum has been 
used with good results. See Serum Therapy. 
Chronic Joint-diseases. 
Hydrarthrosis.-This term is used to designate 
a serous effusion into a joint with a tendency to 
chronicity. Strictly speaking, it is not a disease, JOINTS, DISEASES 
JOINTS, DISEASES 
but a result common to many conditions in and 
about the joints. 
Often in its inception it follows an irritation or 
an inflammation, the acute synovitis becoming 
chronic. On the other hand, effusion is often the 
result of changes in the vicinity of joints. 
A tubercular or gummatous nodule and sarcoma 
of the epiphysis will often be associated with 
hydrarthrosis. Chronic articular rheumatism 
and osteoarthritis, or a retarded circulation, such 
as occurs in phlegmasia alba dolens, may be fol- 
lowed by hydrarthrosis. In very rare cases the 
hydrarthrosis is intermittent. It occurs at fixed 
intervals, and usually in both knees. The knee is 
more frequently the seat of hydrarthrosis than all 
the rest of the joints together. The effusion is 
generally serous. Even after long-continued dis- 
tention of the joints the important ligaments do 
not, as a rule, become relaxed, so that pathologic 
displacements are rarely seen; usually there is some 
muscular atrophy, but contractures do not take 
place. The diagnosis of hydrarthrosis of the knee, 
elbow, wrist, and ankle is easily made. 
Effusions into the shoulder and hip can only be 
recognized when they are quite large. The wave 
of fluctuation in extensive effusion is distinct. 
The articular outlines are effaced, and in the knee 
the ballottement of the patella can be easily 
demonstrated. The chronicity of the condition, 
its slow development, the absence of fever and 
pain, confirm the diagnosis. 
Treatment.-In comparatively recent cases of 
hydrarthrosis absorption may frequently be se- 
cured by the treatment advocated for acute syno- 
vitis with serous effusion. Friction, methodic 
massage, repeated blisters, and the continuous 
application of an elastic bandage will often effect a 
permanent cure. In the failure of these measures 
recourse may be had to immobilization, from which 
the danger of ankylosis is not so great as in the 
cases of acute disease. In the majority of old 
standing cases, however, recourse must be had 
to aspiration of the joint, to be followed by irriga- 
tion with a 5 percent solution of carbolic acid, of 
which from 5 to 10 c.c. may be allowed to remain 
within the joint. To make the injections painless, 
a 0.5 percent solution of cocain may be injected 
before introducing the carbolized water. In cases 
when even this has failed, the draining of the joint 
may be resorted to. 
Chronic Articular Rheumatism.-This is a con- 
dition of advanced life, and often found in the 
lower social strata. Individuals who have always 
been well nourished are not often subject to this 
disease. It occurs oftener in men who have led 
exposed lives; the earlier decades of life are, as a 
rule, exempt. The disease may follow in the 
wake of an acute rheumatic attack; generally it is 
subacute or chronic from its inception. Like its 
acute prototype, it is polyarticular. The patho- 
logic changes of chronic articular rheumatism 
vary with its severity and duration. Joint effusions 
are ordinarily limited in amount, if at all present. 
Primarily, the synovial membrane, the capsule, 
and the periarticular structures are involved. 
The synovial membrane becomes thickened, the 
ligaments indurated, and the periarticular fasciae 
show a tendency to become fixed. 
The symptoms and course of chronic articular 
rheumatism correspond to the morbid conditions 
described. Mild or severe pain in one or more 
joints will be complained of. This is associated 
with restricted movement in the respective joints. 
There is usually an absence of redness over and 
about the joint, and tenderness is never excessive. 
Joint-motion is very often associated with a dis- 
tinct crepitus. With the continuance of the proc- 
ess, restriction of motion and faulty position will 
often eventuate in the disability of an entire limb. 
It is in this way that, by the multiplicity of the 
joints involved, the subject of chronic articular 
rheumatism is often permanently invalided. Acute 
exacerbations of the chronic disease are of fre- 
quent occurrence. 
The diagnosis is ordinarily easily made. The 
conditions with which it may be confounded are 
arthritis deformans and the articular affections 
consequent on diseases of the spinal cord. 
The treatment of this condition is chiefly general. 
During the acute exacerbation sodium salicylate or 
aspirin is as serviceable as in the typical acute 
articular disease. During the intervals alkaline 
waters, particularly those containing lithia, have 
been found efficient. Sulphur and mud-baths, 
when long continued, seem also to have proved 
serviceable. Methodic massage may accomplish 
much in overcoming joint-fixation, hastening the 
absorption of effused fluids, and reducing the 
thickened capsule and periarticular structures. 
Injections, subcutaneously, of fibrolysin are recom- 
mended conjointly with baths, massage, etc. The 
injections are made twice a week into the arm, leg, 
or loins, but not near a joint. 
Arthritis Deformans. 
This is also known as osteoarthritis, chronic 
arthritis, rheumatoid arthritis, arthritis sicca, 
trophic arthritis. It is a condition of degenera- 
tion and proliferation of the structures entering 
into a joint, the morbid anatomy of which forms 
a distinct entity. The causes which bring about 
the changes are far from being clearly apprehended. 
For this reason the disease has been variously 
named according to the views entertained concern- 
ing its nature. For the most part it develops by 
predilection in individuals past middle life, many 
of whom present evidences of arteriosclerosis. Oc- 
casionally it develops in young subjects, especially 
in girls after the appearance of menstruation. 
As the immediate cause, trauma plays a most 
important role, particularly about the hip, rapid 
changes of an osteoarthritic nature following con- 
tusions of and about the trochanter. Within 3 or 
4 weeks most extensive changes may occur which 
simulate the conditions following a fracture. 
Medicolegally, the knowledge of a trauma as the 
exciting cause is of signal importance. 
Since recent studies have shown infectious pro- 
cesses in various cavities and structures as the 
nose, ear, tonsils, etc., and excessive intestinal 
putrefaction, the belief in the infectious origin of JOINTS, DISEASES 
JOINTS, DISEASES 
the disease is gaining ground, while a chronic tox- 
emia due to perverted metabolism is regarded as 
the cause by some observers. 
Symptoms and Diagnosis.-In its clinical mani- 
festations osteoarthritis, except in the rarest cases, 
is characterized by its chronicity and the tendency 
to joint-fixation, not by obliteration of the joint 
cavity, but by the development of osteophytic pro- 
cesses which mechanically impede motion. Pain 
is one of the chief symptoms of this disease. The 
joint, as a rule, shows early the deformation of its 
contour. The ligaments are thickened, promi- 
nent, and indurated; often bony deposits can be 
felt within them and continued into the periarticu- 
lar fasciae and tendons. In the early stages joint 
distention by fluid can occasionally be made out, 
although, as a rule, the process is one in which 
synovial fluid is rather reduced than increased in 
quantity. In accordance with this, the patient 
often experiences a distinct creaking or grating 
when he makes an attempt at motion, and, there- 
fore, stiffness and pain in the part will be com- 
plained of in the morning until the joint has been 
considerably used after a night's rest. Acute ex- 
acerbations following a trauma, for example, or a 
breaking off of one of the osteophytic growths, 
may be followed by hemorrhage or serous effusion 
into the joint. This condition usually subsides 
more readily in cases of this character than in 
joints that are otherwise normal. 
The beginning of arthritis deformans, except 
when it follows a trauma, is ordinarily insidious. 
Pains varying in their intensity, but often severe, 
and associated with creaking of the joints and 
moderate joint effusion, are among the earliest 
clinical manifestations. Very frequently the 
pains are of neuralgic character. In the hip, for 
example, they are referred to the sciatic nerve. 
The joint deformity, however, usually mani- 
fests itself early. Irregular nodules appear, grow 
slowly, and show no tendency toward absorption. 
With the temporary joint effusion and the pain, 
muscular contraction often manifests itself early, 
fixing the joint in an abnormal position. The 
course of the disease is ordinarily chronic, continu- 
ing at times for from 3 to 10 years or more. Ex- 
acerbations consequent on trauma are frequently 
shown; severer injuries may produce fracture or 
dislocation. 
Treatment.-The treatment of osteoarthritis is 
extremely unsatisfactory. Hydrotherapy, spa 
treatment, and hot-air baths, are recommended. 
I nj ections of fibrolysin are advocated by Bannatyne 
and others. Marked improvement has resulted 
from the use of Bier's stasis hyperemia (q. v.). In 
every feasible way joint-movement should be 
maintained by active and passive movements. 
Vibration and massage may also be advantageous. 
Fixation by immobilizing dressing is to be strenu- 
ously avoided. 
Benefit has resulted from the following treat- 
ment: Cod-liver oil, carefully and thoroughly 
rubbed into the affected joints 3 times a day, with 
the internal use of effervescent citrate of lithium, 
1 dram 3 times a day, and the following tonic 
mixture: 
1$. Mass of iron carbonate, gr. v 
Fowler's solution, n^v 
Sherry wine, 
Water, 
each, 3 j. 
After meals, well diluted. 
Sodium salicylate or preferably aspirin, is rec- 
ommended early in the disease. Complete re- 
coveries are reported from the long-continued 
administration in small doses of Fowler's solution. 
Attention to diet and hygiene are also necessary. 
Removal of infection from any portion of the body, 
correction of digestive disturbances and the inter- 
nal administration of tincture of iodin in increasing 
doses in plenty of water one hour before or two 
hours after meals and increasing to point of 
tolerance will be found valuable in many cases. 
Cataphoresis combined with radiant heat is 
recommended highly. The patient, nude, rests 
within a cabinet entirely exposed except his head 
to the radiant heat from incandescent lamps. 
After a 20 minute sitting, cataphoresis with iodin 
ions is employed, the constant current being 
applied to the part after it has been painted with 
iodin liniment, or surrounded by compresses con- 
taining a solution of potassium iodid. See 
Cataphoresis. When structural changes have 
destroyed portions of the j.oint, palliative treat- 
ment is the only indication. Thorough blistering 
or the actual cautery will often remove local ten- 
derness and afford much relief. See Rheumatism. 
Neuropathic Joint-diseases. 
Joint affections may follow any injury of the 
peripheral nerves or of the spinal cord. For the 
most part they are associated with either locomotor 
ataxia or syringomyelia. Neuropathic arthritis 
appears clinically under two forms-the benign 
and the malignant. The former begins as an acute 
or subacute swelling of the j oint and the periartic- 
ular structures. There is a serous effusion into 
the joint which is unattended by fever, pain, or 
redness. It may become rapidly absorbed. The 
malignant type is found exclusively in tabetic 
subjects. With or without absorption of the 
serous effusion the joint capsule remains relaxed 
and weakened, the ligaments show a tendency to 
undergo softening, and the ends of the bones are 
rapidly destroyed by absorption. 
In very rare forms of the disease there is a hyper- 
trophy of the articular ends. In the atrophic form 
the head of the femur may be absorbed, with or 
without leaving a trace. When the knee is 
affected, the entire condylar end of the femur 
and the head of the tibia may disappear. The 
joint becomes flailed, and there is a tendency to 
displacement. In over half the cases the knee is 
affected, the hip, shoulder, elbow, and foot being 
involved in the order named. 
In very rare cases, either spontaneously or 
through trauma, the joint has been opened. 
Such a condition is very apt to be followed by 
very serious consequences as traumatism is 
decidedly injurious to these cases. Not infre- 
quently these joints recover entirely from the JOINTS, DISEASES 
JOINTS, DISEASES 
softening and absorption processes and become 
again useful, though deformed. 
Treatment.-This is palliative. When the effu- 
sion is extreme, temporary benefit may be obtained 
by tapping and the injection of carbolic acid. 
Joint-fixation by retentive dressing aids locomotion. 
Operative interference is contraindicated in these 
cases as the traumatism of opening these joints will 
cause very serious and frequently fatal results. 
varying in size, number, and histologic construc- 
tion, either loose and contained within the joint 
cavity, or adherent at some point by a pedicle of 
varying length and thickness. The joints oftenest 
the site of loose bodies are the knee and elbow. 
The former is involved in nearly 86 percent of all 
cases. In joints that have been free of disease 
these loose bodies-or floating cartilages, as they 
are often termed-are invariably the result of a 
trauma. 
Allied to this class is that known as the internal 
derangement of the knee, in which, in consequence 
of a violent wrench, one of the semilunar cartilages, 
usually the internal, has been loosened from its 
moorings to the tibia and the coronary ligament, 
and is deflected toward the joint-interior. Pri- 
mary laceration of the synovial fringe, or its in- 
filtration with blood and consequent exfoliation, 
may likewise be the source of a foreign body in a 
hitherto normal joint. In diseased joints foreign 
bodies may develop as a consequence of fibrinous 
deposits on the joint surfaces. By organizations 
and long-continued attrition the deposits are broken 
up, as a rule, into large numbers of minute bodies 
varying in size from a grain of mustard to a bean. 
They compress each other into ovoid biconvex 
forms, and occasionally fill the joint cavity. 
These corpora oryzoidoe, or rice bodies, have been 
so called from their shape, size, and pearly appear- 
ance. 
The hyperplastic synovial fringes observed in 
many of the diseases of the joints form another 
common source of these loose bodies, many of them 
floating freely within the joint, others fixed by more 
or less attenuated pedicles to the joint-wall. 
These synovial fringes may present all the histo- 
logic variations of the connective-tissue types found 
in the make-up of the joint; therefore, these 
foreign bodies may be cartilaginous, contain true 
bone, consist of a mass of fat, present a cyst 
within their interior, and, in very rare cases, a 
mass of mucoid connective tissue. 
Symptoms.-The symptoms of loose bodies vary 
with their size, situation, mobility, and the con- 
ditions under which they were developed. When 
they are small and numerous, as in cases of hy- 
drarthrosis, tubercular disease, and arthritis de- 
formans, they produce few symptoms, and rarely 
of themselves require attention. When the bodies 
are larger, the symptoms are far more pronounced. 
Frequently their existence does not make itself 
manifest until the immediate results of the accident 
to the joint have largely disappeared. Thus, after 
a fall upon the knee, for example, a loose cartilage 
will occasionally be discovered a week or ten days 
after the injury, and after a partial subsidence of 
the articular distention with serum and blood. 
In other cases months and years may pass after 
an accident before the loose body is discovered. 
In the largest number of cases the symptoms mani- 
fest themselves in consequence of the locking of 
the foreign body between the articular surfaces 
and the consequent violent stretching of the joint 
ligaments. An individual makes a misstep or an 
awkward movement, and suddenly feels an ex- 
cruciating pain, which compels him to stand 
Hysteric Joints. 
As a result of slight trauma, of overexertion- 
as, for example, in dancing-and very frequently 
without any exciting cause, there develops in hys- 
teric subjects a train of symptoms which, to casual 
observation, may closely simulate organic joint- 
disease. From the time of Brodie the joints thus 
apparently affected have been designated hysteric 
joints. The individuals afflicted are usually girls 
and young women, sometimes pregnant, otherwise 
well nourished, and generally in the higher walks 
of life. They may or may not display other 
phenomena of hysteria or allied neuroses. The 
joints most frequently involved are the hip, the 
knee, and the ankle. Clinically characteristic of 
a hysteric joint is the disparity between the in- 
tensity of pain complained of and the local mani- 
festations. 
Another clinical characteristic of the condition 
is the variability of the position assumed by the 
limb. The variations often follow each other at 
short intervals. A sign to which Brodie called 
particular attention is the intense hyperesthesia of 
the joint and the overlying integument. This is 
more marked even than the tenderness of the joint 
in organic disease, in acute articular rheumatism, or 
in an acute periarticular abscess about to rupture. 
The pain of hysteric joints manifests itself only 
during the waking hours. The starting-pains com- 
plained of at night, so characteristic of some forms 
of organic disease, may be complicated by the ex- 
aggerated suffering of hysteria, but here the per- 
manency of muscular contractures, joint-fixation 
in one position, and the test by anesthesia will 
make the diagnosis clear. 
The progress of a hysteric joint keeps pace with 
that of other manifestations of hysteria. As a 
rule, under proper treatment it disappears rapidly, 
although in exceptional instances it continues for 
months and even years. A hysteric hip has been 
known to withstand all forms of treatment during 
4 years, to become finally dissipated in a single 
night through imagination. 
The treatment of a hysteric joint should be di- 
rected toward the psychic condition of the patient. 
When once thoroughly assured that there is no 
serious disease present, applications of electricity 
and massage will ordinarily speedily cause the 
symptoms to disappear. Too much attention 
should not, however, be given to local treatment, 
and retentive appliances and dressings should be 
strenuously avoided. 
In previously healthy joints or joints that have 
been diseased there are frequently found bodies 
Loose Bodies in Joints. JOINTS, DISEASES 
JOINTS, DISEASES 
where he is or possibly to sink to the ground. 
The limb itself usualy remains fixed nearly in 
extension in the knee; in the elbow, at an angle 
of 130 degrees or 140 degrees. By a little manipu- 
lation the patient, or some one assisting him, 
brings the joint surfaces again into position, and, 
except for some tenderness of the part and tem- 
porary effusion into the joint, a return to an 
approximately normal condition follows. This 
incarceration of the foreign body occurs at in- 
tervals varying between a few weeks and as many 
years. Between the attacks the joint function, 
however, is rarely normal. Limitation of motion 
is very common. In the knee-the foreign body 
being usually in the anterior portion of the joint 
or in the subquadricipital pouch-complete exten- 
sion is not easily accomplished. In the elbow- 
the foreign body lodging more frequently in the 
anterior pouch-flexion to a right angle cannot be 
made. In cases of partial detachment of the semi- 
lunar body it can often be felt in its abnormal 
position, and is but slightly movable. 
A positive diagnosis of a loose body can only be 
made when it is subject to palpation. When felt, 
it appears as a hard, round body under the soft 
parts, usually over the interarticular line or in 
relation with the condyle of the femur. Its 
position can ordinarily be shifted, and, as a rule, 
it disappears from observation, often for long 
periods. Through long experience the patient 
himself is often more successful than the surgeon 
in bringing it to the surface. As to the nature of 
the foreign body, preoperative diagnosis cannot be 
made. 
Treatment.-The multiple bodies which belong 
to the graver joint-diseases, like tuberculosis and 
osteoarthritis, very rarely require surgical inter- 
vention. In the larger bodies, which are the 
important factors in a diseased condition of the 
joint, the treatment is palliative or radical. The 
former consists in the wearing of an elastic bandage, 
which will, in a measure, keep the foreign body 
from lodging between the joint surfaces. The 
radical measure applicable to-day is extirpation. 
To transfix them by needles and bury them with- 
out the joint by subcutaneous measures should 
not now be practised. The excision, as a rule, 
should be made by an ample incision directly over 
the foreign body, ■ which is held by an assistant, 
or, for the time being, transfixed by a needle. 
When, after the incision is made, the foreign body 
is not visible, manipulation of the joint surfaces 
will either bring it to the surface or expose it 
somewhere in the interior. In the latter event it 
can readily be drawn into the wound by means of 
forceps or blunt hook. If there is a pedicle, this 
should be cut off as close as possible, and pref- 
erably without previous ligation. It is always 
wise as far as possible to explore the interior of the 
joint for other foreign bodies, one of which might 
be readily overlooked in its more hidden recesses. 
fungous disease of the joint; caries; and spina 
ventosa. Since the important investigations of 
Friedlander and the discoveries of Koch and the 
causative relation of the specific bacillus to tuber- 
culosis, the term properly reserved for this de- 
structive disease is tuberculous arthritis. This 
disease may attack individuals at any time of 
life, but is most frequently seen before the period 
of puberty. It may develop in infants; 84 per- 
cent of cases occur in children under 14. In 
them the hip, the knee, and the ankle are most 
frequently affected. In adults the wrist, the 
elbow, and the shoulder are often involved. 
Usually the disease is limited to one joint. In 
5 percent of all cases it is polyarticular. Hered- 
ity plays a predisposing role. 
An injury per se produces tuberculosis only 
through the infection of a blood-clot or the forma- 
tion of an infective thrombus in the epiphyseal 
end of the bone. In children the source of tuber- 
culosis is, as a rule, a latent tuberculosis of the 
bronchial lymph-nodes. 
Pathology.-In advanced cases tuberculous 
arthritis includes in its destruction all the joins 
structures. In its inception, however, it begint 
in the epiphyseal end of the bone, when it is called 
osteopathic, or in the synovial membrane, when 
it is known as arthropathic. In children the 
disease is almost always of osseous origin, whereas 
in adults the synovial type predominates. 
1. Osteopathic Arthritis.-This begins, as a rule, 
as a small nodule of reddish-gray or yellowish color 
in the epiphysis. It is situated near the epiphy- 
seal cartilage or directly underneath the articular 
line. Whereas the tuberculous nodule is usually 
single, there may be many. The bone about the 
nodule is distinctly hyperemic. The bone trabec- 
ulae are thickened, the cancellous spaces are 
devoid of fat-cells, and within them are often found 
miliary tubercles. They are often the means of 
extension of the disease. As the central focus in- 
creases in its dimensions it becomes yellowish in 
spots, both from deficient nutrition and fat ne- 
crosis. Thus there are found nodules varying in 
size from a pea to a nut, consisting of soft, cheesy 
material, containing spicules of bone that have 
resisted absorption. This material has been 
erroneously called tuberculous pus. The tuber- 
culous nodule becomes surrounded by a layer of 
granulation tissue, which in turn becomes invaded 
with tubercles, and it is through the growth of 
this granulation tissue that bone absorption takes 
place. Through the growth of the primary focus 
in the direction of the incrusting cartilage the 
joint itself sooner or later becomes involved. 
With the penetration of the disease into the 
joint a panarthritis is speedily developed. The 
synovial membrane loses its smooth appearance 
and becomes covered with fungous granulations. 
Within the joint there is found, as a rule, some 
fluid which is not strictly fluid, but is the product 
of the liquefaction of the cheesy foci and the 
cellular output of the fungous granulations. 
The symptoms of this condition are a manifest 
enlargement of the joint, which is early empha- 
sized by the wasting of the muscles, above and 
Tuberculous Arthritis 
Synonyms.-Among the numerous names which 
have been given this disease are: Tumor alb us, or 
white swelling; scrofulous or strumous disease; JOINTS, DISEASES 
JOINTS, DISEASES 
below. Usually spindle-shaped, covered by an 
anemic, often glistening and adherent skin, 
underneath which a few of the larger veins will 
be seen, the joint now presents the typical appear- 
ance of tumor albus, or white swelling. In the 
majority of cases the capsule itself is softened at 
one or more places, whereby the granulation pro- 
cess becomes extraarticular. Sooner or later the 
skin is broken through, and the products of the 
tuberculous disease escape. Before the rupture of 
such abscesses they are sometimes designated cold 
abscesses. 
As in other abscesses that have discharged, con- 
traction usually takes place until a fistulous open- 
ing is left. In long-standing cases many sinuses 
are often found undermining the periarticular 
tissues. With the breaking of the abscess second- 
ary infection takes place, and the destruction of the 
joint is more rapid than before. 
2. Arthropathic Arthritis.-When the synovial 
membrane is primarily attacked, the tuberculosis 
may be diffusely disseminated over more or less 
tensive serous or serofibrinous exudation is found 
within the joint. This latter, which is known as 
hydrops tuberculosis, must always be taken into 
consideration in the etiology of chronic articular 
effusions. The capsule itself is very often thick- 
ened by excessive vascularization, and as a. prod- 
uct of this a more or less extensive deposit of 
fibrin will be found covering the synovial membrane 
and the articular cartilages. This may be ex- 
tensive enough to cover completely the tuber- 
culous nodules. The partial organization of 
fibrinous deposit from proliferation of endothelial 
layers underneath will often give rise to the de- 
velopment of rice bodies in large numbers, to 
which consideration has already been given. In 
the majority of cases the synovial membrane is 
very much thickened and softened, and within it 
there are disseminated tuberculous foci of larger 
size, which also invade the subsynovial tissues. 
Commonly, there is only a slight increase of the 
synovial fluid, which soon becomes turbid and 
pyoid. As in the osteal form of tuberculosis, 
granulation tissue develops from the surface of the 
synovial membrane, and soon occupies the joint- 
interior. From it are invaded the incrusting 
cartilages. Ordinarily, these present a distinctly 
worm-eaten appearance, and it is from the pe- 
riphery toward the center that the process of in- 
vasion takes place. 
Repair in tuberculous arthritis follows the paths 
by which recovery takes place in tuberculosis else- 
where. Its first evidences are found in the granu- 
lation tissue, which loses its succulence from de- 
creased vascularity, and shows a tendency toward 
conversion into fibrous tissue. In this process 
small caseous masses are often left for years, and 
account for the tendency to recurrence of the 
disease. While it is certain that the bacilli do not 
live throughout such long periods, it is probable 
that their spores live and develop actively after a 
slight trauma, sustained sometimes years after an 
apparent cure has been effected. (Although this 
explanation is hypothetical, it best accords with the 
clinical facts as often seen.) 
Symptoms.-The early stages of tuberculous 
arthritis are, as a rule, vaguely indicated by 
symptoms. With its progress the symptoms be- 
come more pronounced. Those to which attention 
is earliest directed are defective movements, 
swelling, deformity, and muscular wasting. The 
first of these is among the most valuable aids in 
diagnosis. There is early seen a limitation of 
movement, which is most marked in the shoulder 
and in the hip, almost always present in the knee, 
and to a less extent in the wrist and ankle. Tuber- 
culous hydrops, which is oftenest found in the knee, 
may exist without limitation of joint-movement. 
Swelling and deformity are seen early in all cases 
of tuberculous arthritis, except in cases of the hip 
and shoulder. Though seemingly the deformity 
may be due to an enlargement of the bones, this, 
in reality, rarely takes place, and then only as an 
excessive repair. In very exceptional cases there 
is an absolute elongation of bone in consequence 
of tuberculous arthritis. The deformity is very 
frequently enhanced by partial or total luxation 
Tuberculous Hydrops of Knee. 
of the entire area or be limited to one portion 
thereof, preferably one of its reflections or a syno- 
vial fringe. In the diffuse form there may be 
deposited a large number of miliary tubercles, 
without much change in the intervening tissue. 
The joint itself is not much altered. It is occa- 
sionally found in general miliary tuberculosis, of 
which it is only one of the many manifestations of 
infection. In other cases the diffuse tuberculosis 
of the synovial membrane is associated with in- 
creased vascularity, as a product of which an ex- JOINTS, DISEASES 
JOINTS, DISEASES 
In the knee there is a tendency toward subluxation 
backward of the tibia on the femoral condyles, the 
latter becoming abnormally prominent. In the 
hip what is left of the femoral head often leaves 
the deformed acetabulum, thereby producing great 
deformity, with shortening. The deformity is al- 
most always enhanced by vicious joint-fixation. 
Reflex contractures, invariably of the stronger 
flexor muscles, and angular deformity speedily 
ensue. The knee is flexed upon the thigh; the 
elbow becomes flexed at an angle of 120 degrees 
to 130 degrees; the wrist drops; the hip is flexed 
upon the abdomen; and the foot assumes the talipes 
equinus position by the contracture of the stronger 
muscles which act upon the joints named respec- 
tively. The contracted muscles can always be felt 
early as well-defined ridges in close proximity to 
the angle in which the limb is fixed. With the 
contracture there is often associated an atrophy of 
the muscles as an early evidence of the disease. 
Although the degree of atrophy may not at first be 
measurable, the flabby condition of the muscles 
is significant of its presence. 
Pain varies materially at different periods of the 
disease and in the various types. It is most 
marked in the osteopathic form of the disease. In 
the synovial type, even when associated with 
large effusion, it may be slight or altogether 
absent. Whereas, as a rule, the pain is experi- 
enced in the joint involved, it may be reflected, as 
is the case notably in the hip, to parts far removed. 
Through fixation of the limb by muscular contrac- 
ture motion does not necessarily increase pain. 
Children with advanced disease of the hip or of 
the knee often do not suffer at all, even from violent 
exercise. By substituting the functions of other 
joints for that of the one diseased, motion in the 
latter is involuntarily reduced to a minimum. 
The constitutional complications of tuberculous 
arthritis are rarely marked in the early stages. 
Adults and children are seemingly in perfect health, 
except for the local condition. In proportion as 
this extends the general condition suffers. 
The diagnosis of tuberculous disease is, as a rule, 
easy. In fully 90 percent of the cases it is almost 
self-evident. Far more difficult is it to distinguish 
the individual types of the disease. The fungous 
variety of the superficial joints, like the knee, 
elbow, wrist, and ankle, is very easily recognized 
by the swelling, the deformity, and the sense of 
false fluctuation. More difficulty attaches to the 
recognition of a deep-seated tuberculous nodule 
within the epiphysis. The condition with which 
this is most easily confounded is the epiphyseal 
gumma of late inherited syphilis. The presence 
of corroborating evidences of syphilis, rapidity of 
development, and, above all, the therapeutic 
test, will, as a rule, make the diagnosis clear. The 
perfection of the X-ray now renders possible the 
very early discovery of a focus of disease in a bone 
end or joint and readily differentiates it from 
the possible complications. 
From arthritis deformans tuberculous disease is 
easily distinguished by the chronicity of the former, 
the enlargement of the articular ends of the bones, 
and the tendency to osteophytic growth. 
Prognosis.-The prognosis of tuberculous arthritis 
depends very largely upon the treatment instituted 
and upon the degree of local disease when it first 
comes under observation. With proper treatment 
the disease may be arrested in its incipiency, and 
it is possible for complete restitution to occur. In 
the great majority of cases, however, the best that 
can be hoped for is a limitation of joint-function, 
either from the partial obliteration of the joint 
cavity or from the development of fibrous adhe- 
sions. 
Treatment.-The treatment of tuberculous ar- 
thritis must be based on the natural tendency of 
the disease toward recovery. With or without 
deformity such recovery ensues-in disease of the 
spine, for example, when operative influence can- 
not be resorted to early. Conservatism, therefore, 
must be the rule of treatment, and only after 
failure should there be resort to active interference. 
Since tuberculous arthritis is but the local ex- 
pression of an infectious disease, general measures 
are not to be overlooked. An abundance of 
fresh air, a suitable diet, and attention to cleanli- 
ness are of first importance. The internal ad- 
ministration of guaiacol and of creosote has been 
found beneficial. In the hands of very many Con- 
tinental surgeons the modified tuberculin treat- 
ment has also been followed by excellent results. 
See Tuberculosis. 
The local treatment of tuberculous arthritis should, 
in the first place, be directed toward securing ab- 
solute rest for the joint. A prolonged rest in bed 
will often at once relieve pain and swelling, and 
even if prolonged through many months, will not 
interfere with the nutrition of the patient. Local 
rest is best obtained by the use of a retentive dress- 
ing of plaster-of-Paris, of starch, or of silicate of 
sodium, applied with sufficient snugness to dis- 
tinctly compress the distended j oint. In the j oints 
of the lower extremity, except the hip, and of the 
upper limb, except the shoulder, and in tubercu- 
losis of the spine, such retentive dressings are 
often the most serviceable of the methods of 
treatment. 
In the inception of the disease traction (exten- 
sion) is also very serviceable, particularly in over- 
coming the tendency toward the contracture of 
the flexor muscles. During the acute stages such 
traction can be best maintained with the patient 
in the recumbent posture, whereas later some 
form of traction splints can be successfully used. 
In tuberculous arthritis of the upper extremity the 
use of extension is far less valuable. When the 
contractures are firm enough to resist' traction, an 
open division of the contracted parts should be 
made. 
In very many cases it is advisable to attack the 
tuberculous disease directly by agents which dis- 
tinctly destroy the bacillus or unfit its soil for 
necessary sustenance. Such agents are zinc 
chlorid, balsam of Peru, and particularly iodo- 
form. The direct injection of either of these 
agents into a tubercular focus at intervals varying 
from 4 to 5 days to as many weeks will often obviate 
the necessity of a more or less crippling operation. 
The zinc chlorid may be used in the saturated or JOINTS, DISEASES 
JOINTS, INJURIES 
50 percent solution, and from 4 to 5 minims in- 
jected. The balsam of Peru is injected undiluted. 
Iodoform may be employed in 10 to 20 percent 
solutions in sterilized glycerin or olive oil, and in- 
jected in quantities varying from 1 dram to 2 
ounces. To avoid iodoform intoxication it is best 
to begin with a smaller quantity. While the 
injections are being made the urine should be 
carefully examined, since the gravest result of 
intoxication has been found to be parenchymatous 
nephritis. The iodoform solution should always 
be sterilized by submersion of the iodoform during 
4 days in a 1:1000 solution of corrosive sublimate; 
it should then be thoroughly washed in sterilized 
water. The glycerin, and particularly the oil, 
should be sterilized by boiling. 
Bier's hyperemic treatment (q. v.) and open air 
are valuable adjuncts to the iodoform injections. 
The suction cup is especially beneficial in open 
lesions. 
When many fibrinous shreds come away through 
the cannula, it is advisable to incise the joint freely, 
with proper aseptic precautions, and thoroughly 
irrigate it with a saturated boric solution before 
making the iodoform injection. If necessary the 
incision may be sufficiently enlarged to make the 
operation exploratory, the incision being closed 
immediately after the injection has been com- 
pleted. For a cure of tuberculous arthritis from 
3 to 20 injections may be necessary, and the time 
required to effect a cure varies from 2 months to 
1 year. 
Hydrops tuberculosis will often disappear under 
rest and compression. In the failure of this, as- 
piration should be resorted to, to be followed by 
the injection of carbolic acid or iodoform. The so- 
called cold abscesses require special attention in 
many cases although when they are limited in size, 
they may be allowed to take care of themselves. 
Through defective operative treatment, septic in- 
fection, which may rapidly be destructive to joint 
and life, has often been induced in the past. 
If conservative and mechanic measures fail, 
operative treatment must be resorted to. A free 
incision of the joint (arthrotomy) is the simplest 
measure. By arthrectomy, or joint erasion, the 
removal of fungous masses from the synovial 
membrane and the incrusting cartilages is made 
possible. If necessary the entire synovial mem- 
brane may be removed, and with the chisel or 
sharp spoon tubercular foci can be taken from the 
epiphysis. This operation is an atypical resection. 
The wound may be entirely closed or provision 
made for drainage by a strand of silkworm-gut. 
Resection for tuberculous arthritis, formerly very 
extensively practised, is for good reasons less and 
less employed. If done before puberty, a great 
shortening of the limb will often result. Resection 
is indicated in children and young adults only 
after arthrectomy has failed. In persons beyond 
the age of puberty excisions are more often called 
for. Excision for tuberculosis of the larger joints 
is often reserved for the correction of deformity 
after the tuberculous process has healed spontane- 
ously or through the methods of treatment, 
operative and otherwise, already mentioned. In 
tuberculosis of the wrist and of the foot total ex- 
cision of the bones involved is to be resorted to, 
rather than the excision of the focus and its 
evacuation by curette or chisel. It is particularly in 
these cases that operative infection of contiguous 
joints and of overlying tendon sheaths is likely to 
occur. 
In the absence of such infection the shell of bone 
which is left after the operation is filled with a clot 
which readily becomes infected, and in the con- 
trary event is difficult of organization. 
In severer cases of tuberculosis of the wrist or 
tarsus amputation will often afford the patient the 
quickest and safest road to recovery. Amputation 
must likewise be resorted to at times in children in 
whom the tuberculous and secondary suppurative 
processes have left the region of the joint riddled 
with sinuses and the bones destroyed over ex- 
tensive areas. In the lower extremity such am- 
putations must be made oftener than in the upper, 
but in both, with the improved surgical technic of 
recent years, the mortality following them has been 
reduced to a minimum. See HiP-joiNT (Disease). 
JOINTS, EXCISION.-See Excision of Joints. 
JOINTS, INJURIES. Contusion.-This is the 
simplest injury to which a joint is liable. It usu- 
ally results from direct violence, such as a blow or 
fall. Occasionally it is the result of indirect 
violence. This is generally the case in contusion of 
the small joints of the hand and foot. When 
severe, a contusion makes itself manifest by hemor- 
rhage into the periarticular tissues. 'Within 24 
hours or more the blood permeates the subcutane- 
ous layer and appears in the form of ecchymoses 
of greater or less extent. In the severe forms of 
contusion considerable hemorrhage into the in- 
terior of the joint takes place. Swelling of greater 
or less extent, with loss of the normal joint outline, 
will make easy the recognition of this condition. 
Pain, as a rule, is never very severe, the incon- 
venience of the joint-movement and tenderness on 
pressure being the only subjective symptoms. In 
exceptional cases, however, pain is often severe 
enough to produce faintness. Even in these cases 
its duration is short. When there is an extensive 
hemorrhage into the joint, a slight rise of tempera- 
ture may result during the first 24 or 48 hours. 
The treatment of contusion consists of rest, 
evenly applied bandages, and elastic compression. 
If much pain is complained of, applications of ice 
during the first 24 hours will often give great relief. 
After the lapse of 2 or 3 days, passive movements 
should be made and systematic massage of the 
joint practised. 
Sprains of joints are considered under Sprains 
(?• v.). 
Penetrating Wounds.-The injuries of joints 
hitherto considered may prove serious to the func- 
tion of the limb, but being subcutaneous, they 
never, per se, jeopardize either limb or life. In 
strong contrast to these, therefore., are the wounds 
in which communication is established between 
the external air and the joint-interior. Penetrat- 
ing wounds, particularly of the larger joints, like 
the knee, the hip, the shoulder, and the ankle, may, 
and often do, become among the gravest of the JOINTS, INJURIES 
JOINTS, INJURIES 
injuries to which the body is subject that are not 
immediately fatal. 
A joint wound becomes dangerous only through 
infection. That mere opening into a joint is free 
of danger is displayed daily in the operating-room. 
Aspiration, puncturing with a trocar, free incision 
for the removal of foreign bodies, with the proper 
precautions as to ascepticism, involve no danger. 
A wound of the synovial membrane heals by 
primary union, as does a wound of the skin. The 
great danger of infection of a joint from a pene- 
trating wound lies in the complicated construction 
of many of the joints, the difficulty in securing 
adequate drainage, the communication normally 
present between the joint and surrounding bursae, 
and the ease with which the connective-tissue 
planes about the joint are involved in the diseased 
process. 
Penetrating wounds of the joint may be divided 
into the incised, the punctured, the lacerated, and 
the gunshot injuries. In very many instances the 
wound is complicated with more or less extensive 
injury to the surrounding structures, particularly 
the bones, the larger blood-vessels, and the nerve- 
trunk. For practical purposes simple incised 
wounds may be differentiated from the com- 
plicated forms, for in the latter the opening of the 
serous cavity is less significant than the concomi- 
tant injury to bone, blood-vessel, or nerve. In 
civil practice the injuries most frequently seen are 
of the punctured or incised variety. The shoe- 
maker thrusts an awl into his knee, or the wood- 
man sinks his ax into ankle or knee; the mechanic 
occasionally thrusts a pointed instrument into 
the wrist-joint. The wound of communication, it 
will therefore be seen, varies in its size, being often 
so small as to be just perceptible, or large enough, 
on the other hand, to afford a view of the joint- 
interior. In the latter instance the diagnosis is, 
of course, simple; in the former, on the other hand, 
it may be difficult to recognize the penetrating 
nature of the injury, and often it is impossible. 
Symptoms.-Cardinal signs indicative of pene- 
trating joint-injury have been said to be the out- 
flow of synovial fluid, pure or mixed with blood, 
and, in the absence of this, the rapid filling up of 
the joint cavity with blood. Neither of these signs 
is pathognomonic. The opening of a periarticular 
bursa or of a tendon sheath will permit the outflow 
of a fluid closely allied to the synovial. When the 
perforation is small, the opening in the joint closes, 
and will allow no permeation of fluid through the 
wound tract. The accumulation of fluid within the 
joint, on the other hand, will often attend con- 
tusion of the joint without perforation. It is not 
uncommon, for example, to find, in consequence of 
falls upon the knee, a contused and lacerated 
wound of the periarticular structures, followed by 
hemarthrosis, without penetration of the joint. 
In compound fractures of the epiphyses joint- 
penetration may often be suspected, but is rarely 
subject to demonstration until, in neglected or 
badly treated cases, the joint reacts to septic in- 
fection. When the diagnosis cannot be otherwise 
established, the careful use of a sterilized probe 
may bring certainty. In small, punctured wounds 
the displacement of the tract between muscles 
and tendon sheaths will often render the search 
futile. If indications arise demanding a positive 
diagnosis, an enlargement of the wound under 
anesthesia and exploration of its course must be 
made as the preliminary step of the proper opera- 
tive treatment. 
Punctured and small incised wounds of even the 
largest joints are not, as a rule, attended by severe 
constitutional disturbance. A man with a punc- 
tured knee may follow his vocation for a day 
or two without any marked local or general dis- 
turbance. In the lacerated wounds, on the other 
hand, there is, as a rule, very great depression. 
Being often associated with fracture or dislocation, 
and accompanied by profuse bleeding, the shock 
manifested is often extreme. 
The clinical course of these injuries depends 
wholly on the presence or absence of primary 
wound-infection. In the latter even large wounds 
heal by first intention without local or general 
reaction. The continued outflow of synovia for 
several days, while it jeopardizes so fortunate a 
result, does not annul it. 
In the presence of infection the course will be 
determined, to a large degree, by the nature of the 
infection, the facility for drainage, and the treat- 
ment instituted. The introduction of the less 
virulent pus-microbes into punctured wounds may 
be followed by a period of quiescence varying from 
2 days to a week. The vascularization of the 
synovial tunic is then made evident by a serous 
articular effusion, which speedily becomes turbid 
and contains flakes of lymph. The joint and peri- 
articular tissues become reddened, disfigured, pain- 
ful, and tender. Often a chill announces the in- 
ception of the suppurative process. In evidence 
of systematic toxemia there is a continuous fever 
with morning remissions, which continues while 
intraarticular pus-retention exists. In these 
milder forms of traumatic synovitis, if ample 
opportunity for drainage is afforded, the integrity 
of the joint may still, to a large extent, be main- 
tained. The outflow of the pus through one or 
more openings reduces the intraarticular tension, 
the discharge in the course of a few weeks becomes 
reduced to a minimum, the cartilaginous covering 
may even be left intact, and the joint saved with a 
fair degree of function. 
In the cases of grave infection with insufficient 
drainage, the joint structures soon undergo 
changes that place them beyond repair. The 
synovial membrane becomes greatly thickened, 
the surrounding ligaments become softened, the 
cartilage covering the bones raised at first in areas, 
then separated altogether from the underlying 
bone. The joint structures thus become almost 
altogether unrecognizable. Communications are 
established between the pus-cavity into which the 
joint has been converted and the bursae originally 
communicating with the joint tendon sheaths over- 
lying them. In this way a joint-abscess finds its 
way to the surface, often in as many as from 3 to 
6 places, removed from each other by considerable 
distances. While this process in and about the 
joint is going on, the limb becomes often enor- JOINTS, INJURIES 
JOINTS, INJURIES 
mously swollen, the general septic manifestations 
are very marked, and, unless relief is afforded, 
death may sooner or later occur. But even in 
such unfortunate cases life and limb are often pre- 
served after protracted suppuration, lasting at 
times for many months. 
As in wounds of the soft part, those of j oints that 
are primarily infected with the more malignant 
pus-formers (the streptococcus infection), if left 
to themselves, often run a more rapidly fatal 
course. From the very beginning the general 
manifestations of sepsis are graver. Within 24 
hours of the injury the joint is already enormously 
tumefied. Within 48 hours the discharges are 
slightly putrid, and often an examination of the 
joint reveals free gases in the interior. In these 
cases ascending phlebitis of the deeper veins often 
leads to rapidly spreading gangrene of the extrem- 
ity. In one case of a wound of the knee with such 
gave primary infection gangrene had developed 
within 24 hours; within 30 hours the gangrene had 
spread to the hip, ending fatally within 33 hours 
from the infliction of the injury. Between these 
extremes in the clinical course of penetrating 
wounds of the larger joints there are all degrees of 
rapidity and virulence of symptoms consequent on 
infection. 
In penetrating wounds of the smaller joints, par- 
ticularly of the hand and foot, owing to their 
greater simplicity, the local and general manifesta- 
tions are proportionate to the size of the joint 
injured. Whereas, as a rule, the function of the 
joint involved is permanently restricted, the in- 
fection remains localized and limited, and life is 
rarely threatened. But even in this regard 
caution in prognostication is essential, since the 
extension of disease to parts far removed from the 
primary injury occasionally ensues. 
The treatment of penetrating wounds of the 
joint must have for its objects: First, the securing 
of primary union through the prevention of in- 
fection; and, second, the treatment of the trau- 
matic arthritis when the infection has already 
taken place. To meet the first condition is simple 
when the diagnosis is clear. Like wounds in 
other parts, joint wounds must be thoroughly 
cleansed. Unevenness of the surface and con- 
tused edges must be removed by clean incisions, 
and the joint should be thoroughly explored for 
parts of the vulnerating body which have possibly 
remained. embedded in it. To accomplish this, 
the wound into the joint may, without fear, be 
very much enlarged. The joint cavity is then to 
be thoroughly irrigated with a sublimate solution 
of 1 to 4000. If there has been much oozing, a 
silkworm-gut strand may be left for drainage. 
The wound is closed by sutures, and the joint, 
being aseptically dressed, kept at rest. 
When the diagnosis of joint-penetration is in 
doubt, the treatment should depend largely upon 
the facilities for aseptic exploration at the com- 
mand of the surgeon. Without such facilities it is 
probably wiser to await the development of 
symptoms indicative of infection before resorting 
to operative interference. When the surgeon has 
control of his surroundings, it is advisable, as in 
cases of doubt pertaining to penetrating wounds of 
the abdomen, to enlarge the punctured or incised 
wound, to trace it to the joint capsule, and, if this 
is found to be penetrated, to treat it as in the 
cases just considered. With the first evidences of 
septic infection, in either class of cases, the treat- 
ment must consist of the antiseptic management 
of the joint-interior. By this is meant a free in- 
cision for the removal, through drainage, of the 
contents of the diseased joint and antiseptic 
irrigation of the joint-interior. In proportion as 
these objects are sought early or late, the integrity 
of the joint will be more or less maintained or 
entirely lost. 
In the management of traumatic suppurative 
arthritis the position of the limb should be kept in 
mind, with a view to probable future ankylosis. 
Left to itself, a suppurative arthritis of the knee 
will invariably leave the limb much flexed; of the 
elbow, the arm slightly so. An early regard for the 
position to be attained is therefore an essential 
element of treatment. 
When the penetrating wound of a joint is only 
one feature of a complicated trauma, the question 
of primary excision, or even of amputation, may 
arise. For uncomplicated wounds of the joint 
neither of these operations is primarily indicated. 
In cases of compound dislocation, with fracture 
into the epiphysis, particularly in the upper ex- 
tremity, a primary excision will often save a useful 
limb. The same is true of compound dislocations 
of the ankle. In a compound dislocation of the 
knee the force producing it is necessarily so great 
as to make the joint injury of secondary impor- 
tance. In such a case primary amputation must, 
as a rule, be resorted to. 
Gunshot Injuries.-Gunshot wounds of the joints 
are always lacerated and contused, and for this 
reason alone afford a better soil for infection. In 
the wounds made by larger missiles there is always 
added considerable injury to the epiphyseal ends 
of one or both of the contiguous bones. In these 
wounds the epiphyses are often shattered beyond 
repair, and the larger vascular or nerve-trunks are 
often involved to a degree calling for immediate 
amputation. A gunshot wound of a larger joint 
by a ball of larger caliber, when left to itself, often 
pursues a rapidly fatal course. Of 271 joint in- 
juries in the Russo-Turkish war (tabulated by 
Reyher), 146 proved fatal; mortality, 54 percent. 
From the very first day the joint becomes tender, 
the slightest movement giving rise to excruciating 
pain. The integuments become discolored, the 
veins distended, and gas-formation in and about 
the joint rapidly takes place. The constitutional 
symptoms accord with the degree of the local in- 
fection: the temperature ranges between 103° and 
105° F., the sensorium becomes obtunded, delirium 
develops, and the patient, if unrelieved, often dies, 
in from 3 to 5 days, of acute septicemia. In the 
gunshot wounds of joints made by small arms, as 
seen in civil practice, the symptoms are far less 
pronounced. They accord -with those described of 
the milder infected wounds that are penetrating 
from other sources; but even in these, owing to the 
damage done to contiguous bones and the presence JOINTS, INJURIES 
JUGULAR VEINS, SURGERY 
of foreign substances, the symptoms develop more 
rapidly. In wounds produced by the larger mis- 
siles fired from modern arms there is usually per- 
foration, under which circumstances, as in gun- 
shot injuries elsewhere, the w'ound of entrance is 
smaller than that of exit, and has a tendency to 
contract. The wound of exit is larger, often 
gaping, and on exploration presents detached 
spicules of bone. In wounds made by missiles of 
small caliber, perforation of the larger joints is not 
common. The missile may rarely be found loose 
between the joint surfaces. Often it is found 
firmly embedded in the epiphysis, after having 
produced more or less splintering. 
The diagnosis of gunshot injuries of the joints by 
larger missiles is always simple. The probe, or 
preferably the finger, thoroughly sterilized, can be 
made to freely enter the joint cavity and detect 
the damage done. In the injuries produced by 
balls of small caliber the diagnosis is likewise, as a 
rule, easily made. The outflow of synovia mixed 
with blood, the rapid filling of the joint with fluid, 
the crepitus detected by manipulation, the im- 
pairment of j oint-motion due to the presence of the 
missile or fragments of bone, make the diagnosis 
clear. There are, however, cases in which doubt 
must remain, as in the cases of other than gunshot 
wounds in the cavity of joints. In these cases, 
the X-ray will entirely clear up any possible 
doubt and should be used whenever possible. 
Wounds made by the smallest caliber revolvers or 
rifles ordinarily do little damage, the propelling 
force being slight, and they rarely carry before 
them particles of infected clothing. If left to 
themselves, primary union or healing under a 
blood-clot ensues, as in similar wounds of the soft 
parts. In wounds by larger missiles, even those 
from large revolvers, the source of wound con- 
tamination is chiefly in particles of clothing pene- 
trating with the ball. The ball, as it comes from 
the manufacturer, has been shown to be almost 
sterile; the temperature to which it is raised in its 
course and by impact is insufficient to sterilize the 
foreign substance which it carries into the wound 
before it. In 3 out of 5 pistol-shot wounds of the 
knee recently recorded, particles of clothing were 
found in the track of the wound. 
In joints with subtendinous pouches, like the 
elbow and the knee, penetration not infrequently 
occurs without injury to the bone. A similar 
penetration may occur, for example, from a 
wound in the anteroposterior axis of the knee 
without injury to the bone when the leg is flexed 
at an angle of about 140 degrees. 
Treatment.-The course of healing is greatly 
influenced by the initial treatment. This is 
particularly true of gunshot wounds of joints. 
Except when profuse hemorrhage calls for im- 
mediate care, the first attention should be limited 
to the application of an antiseptic dressing. More 
should not be done until the best possible facilities 
are afforded for antiseptic and aseptic manipula- 
tions. Above all things, probing with finger or 
instrument can only be harmful unless every pre- 
caution toward surgical cleanliness is observed. 
Conservatism in the sense of antisepsis and im- 
mobilization is indicated in cases of smaller 
wounds, such as are seen in civil practice. In all 
other gunshot injuries of joints conservatism is 
probably most favored by primary operative 
treatment. Delay until the manifestations of 
infection compel a tardy interference entails dis- 
aster to life and limb more often than in joint 
wounds from other causes. This has been estab- 
lished beyond a reasonable doubt. 
According to the varying conditions found, re- 
course must be had to exploration and lavage of 
the joint, atypical excision, or amputation. In 
civil practice the latter will rarely be demanded; 
even in military practice it will probably be re- 
served for the complicated injuries, of which the 
joint-penetration is only one element. Extensive 
injury to the soft parts, communication of both 
epiphyses and fracture extending into the diaphy- 
sis, injury to larger nerves and vascular trunks, are 
the conditions demanding primary amputation. 
As for severe injuries from other causes, amputa- 
tions of the lower extremity, other things being 
equal, will be more often demanded than those of 
the upper. In the smaller wounds seen in civil 
life, when the diagnosis is clear, the facilities for 
asepticism should determine the course; without 
them, an expectant treatment limited to thorough 
cleansing of the wound and immobilization should 
be trusted to, rather than exploration. • 
With facilities for aseptic work at hand even 
the smaller wounds seen in civil life should be 
subjected to immediate exploration. The wound 
should be enlarged and the site of joint-penetra- 
tion thoroughly exposed. When it is required 
for further manipulation, a free incision into the 
capsule must be made. With the parts so ex- 
posed the course of the ball can ordinarily be easily 
followed. If it has plowed its way into an epi- 
physis, the canal should be enlarged with chisel 
and sharp spoon until it is found and dislodged. 
Loose spicules of bone are to be removed with the 
forceps and uneven projections chiseled away. An 
atypical resection may thus be made. Particular 
care must be given to the removal of foreign sub- 
stances carried in with the missile. If, in perforat- 
ing wounds the manipulations have brought the 
operator near the distal side of the joint, a coun- 
ter-opening should there be made. Ample facility 
for drainage is the condition on which success de- 
pends. After such atypical resection fair joint- 
motion is often retained. If both epiphyses are 
injured, it is probably wiser to make a formal ex- 
cision, in order to obtain ankylosis. See Gunshot 
Wounds. 
JUGULAR VEINS, SURGERY.-The physical 
signs of importance in connection with the jugular 
veins are distention, pulsation, and venous hum. 
Venesection of the external jugular vein is per- 
formed in cases in which congestion of the brain, 
asphyxia, or similar indication exists, and is done 
at the root of the neck. The patient usually is re- 
clining, a pillow beneath the shoulders and the 
head turned to the opposite side. A small cork 
or pad of lint (hard) is placed over the vein as it 
dips under the clavicle at the outer border of the 
sternomastoid muscle and held by the thumb or a JUNIPER 
JURY-MAST 
bandage passing beneath the opposite axilla. The 
vein is to be opened as it lies on the surface of the 
sternomastoid, the incision in the same direction 
as the fibers of the muscle. To arrest the bleed- 
ing, a compress is placed on the wound and held 
by the thumb until the pad has been removed. It 
is important to avoid the possibility of air passing 
down the vein. 
Wounds of the external jugular are usually 
quickly fatal, owing to the great loss of blood or to 
the entrance of air into the circulation. The direc- 
tion of the wound is important, as a transverse 
wound is held wide open by the action of the deep 
cervical fascia, and a longitudinal wound will 
not gape. If the internal jugular is wounded 
near its entrance into the skull, septic infection, 
venous and sinus thrombosis are additional 
dangers to the loss of blood and entrance of air. 
See Neck (Injuries). 
JUNIPER.-The fruit of Juniperus communis; 
its properties are mainly due to a volatile oil, 
and it is a stomachic tonic, diaphoretic, diuretic, 
and aphrodisiac. The oil is eliminated by the 
kidneys. It is valuable in chronic pyelitis and 
cystitis; but is contraindicated when acute 
nephritis is present. J., 01., the volatile oil. 
Dose, 1 to 5 minims. J., Spt., 5 parts of the oil 
in 95 parts of alcohol. Dose, 1 to 4 drams. 
J., Spt., Comp., the gin of commerce; oil of juniper 
8, oil of caraway 1, oil of fennel 1, alcohol 1400, 
water sufficient to make 5000 parts. Dose, 
1 to 4 drams. J. oxycedrus affords oil of cade. 
Oil of Cade, a tar-like substance obtained by the 
distillation of juniper wood; it is sometimes used 
externally in eczema and psoriasis. 
JUNKET.-Curds and whey; a delicacy for 
invalids, prepared by taking 1/2 pint of fresh milk 
heated to an agreeable tempera- 
ture, adding 1 teaspoonful of 
rennet or essence of pepsin and 
stirring well. Let the mixture 
stand until curdled, and serve 
with sugar and nutmeg. 
JURY-MAST.-An appliance 
devised to produce fixation of 
the spine, when the disease is 
above the middorsal region of 
the back, supporting the head 
and neck. The jury-mast con- 
sists of a vertical steel bar 
shaped to the curves of the head 
and neck, and attached to this 
steel bar is a sling which sup- 
ports the chin and occiput. 
The lower end of the bar may 
be incorporated with a plaster jacket or riveted 
to a leather or poroplastic jacket. See Spine 
(Caries). 
Sayre's Jury 
Mast. - {Stewart.) kakk£ 
KELOID 
K 
KAKKE.-See Beri-Beri. 
KALA-AZAR. A chronic infectious disease 
widely distributed in certain parts of the tropics 
and characterized by persistent remittent fever, 
great splenic as well as hepatic enlargement, 
anemia, emaciation, and dysenteric symptoms. 
Hemorrhages into the skin and mucosa may be 
observed. Ulcers may appear on the skin or 
mucosa. The disease is probably caused by the 
Leishman-Donovan parasite, a form of trypano- 
some. The organism is obtained by splenic or 
hepatic puncture. This procedure should be re- 
sorted to for accurate diagnosis after the possi- 
bility of leukemia has been eliminated. The 
parasites are also found in ulcerations, bone mar- 
row, and lymph glands near lesions and rarely 
in the peripheral blood. These bodies are round 
or oval, sharply outlined when stained, usually 
grouped in rosettes. Concurrent with this dis- 
ease, malaria or hookworm disease may be 
found. The disease is fatal, death ensuing 
sooner or later from exhaustion or intercurrent 
disease. Isolation and quarantine should be 
insisted upon. 
KATATONIA (Alternating Insanity).-A men- 
tal disease characterized by irregular cyclic 
symptoms, ranging from melancholia to mania, 
followed by stupidity and confusion, with catalep- 
toid phenomena, and by lucidity for a time, 
recovery, or passing to a dementia. There may 
be a hereditary predisposition. The exciting 
causes are usually the result of some excess. It is 
rarely associated with organic brain-disease. No 
characteristic lesions have been found associated 
with katatonia. 
A typical case begins with melancholia, the 
mental depression, uneasiness, and distress fol- 
lowed after a variable period by mania, associated 
with hallucinations and delusions. This period is 
followed in turn by a condition of attonita, or rigid- 
ity and immobility, or a cataleptoid paroxysm. 
Any of the stages may be succeeded by confusional 
symptoms, or a true dementia may develop. 
During the maniacal stage there is a tendency in 
many cases to histrionic and sermon-like decla- 
mation, or the speech may be of the verbigeration 
character-that noisy, incoherent, and meaning- 
less speech seen in many manias, composed largely 
of the constant repetition of a few words or 
phrases. During the stage of attonita the pres- 
ence of the so-called mutism, or mutacismus, 
"a pathologic tendency to be silent," may con- 
tinue for days, weeks, or months, or it may be in- 
terrupted by periods of verbigeration. The im- 
mobility or rigidity so characteristic of a period 
of katatonia is frequently alternated with auto- 
matic, incessant, and monotonous movements- 
the stereotyped movements. 
Patients suffering from katatonia often refuse 
food for days at a time, and then suddenly present 
symptoms of bulimia. Vasomotor and trophic 
changes are frequent, one of the most constant 
being cyanosis of the hands and other peripheral 
parts. Hematoma of the ear, insane ear, or peri- 
chondritis of the auricle, is frequent. Epilepti- 
form attacks may usher in the disease or occur dur- 
ing any of its stages. Katatonia differs from 
circular insanity in the absence of a genuine lucid 
interval, and the presence of the stage of attonita 
and catalepsy. The disease may continue for 
a number of years and recovery follow, but, as a 
rule, the prognosis is unfavorable. 
Treatment consists in attention to the general 
condition, and combating the various symptoms 
as they arise. In cases associated with anemia, 
arsenic and strychnin seem to be valuable. Two 
cases were rapidly improved with small doses of 
hyoscin hydrobromid, 1/300 to 1/200 of a grain, 
morning and evening. 
KEFIR.-A fermented drink prepared from the 
milk of a cow or mare by the addition of a mush- 
room-like ferment found in the Caucasian Moun- 
tains. It is used by the natives of the Asiatic 
plains as a remedy for struma, anemia, lung and 
stomach diseases. Kefir is richer in albuminoids 
than Kumyss, is less alcoholic and less acid. 
The following table shows the average composi- 
tion of Milk, Kumyss and Kefir:- 
Cow's milk. Kumyss. 
Kefir. 
Albuminoids (casein, etc.). .. 
4 1 
4 
Butter, 
4 2 
2 
Sugar of milk, 
5 2J 
2 
Lactic Acid, 
- 1 
1 
Alcohol, 
- U 
1 
Water and salt, 
87 92 
90 
KELENE.-See Ethyl Chlorid. 
KELOID (Cheloid).-A tumor of the skin 
resulting from overgrowth of connective tissue 
within the corium, arising from preexisting scar 
tissue or inflammatory exudation. The scars 
from lupus, burns, and syphilis are especially prone 
to it, and it may arise from the scars of boils. 
Colored races are more affected than the white, 
brunets more than blonds. It is most common 
in the middle-aged. It is more frequent over'the 
sternum and about the shoulders and neck. 
Keloid seldom gives rise to much inconvenience, 
and when left to itself, progresses slowly or re- 
mains stationary for life or years, and may dis- 
appear spontaneously. It has no tendency to 
desquamation or ulceration. 
Keloid formed in scar tissue should never be 
removed by the knife or caustics, since it always 
returns quickly. Left to itself, it has a tendency 
to undergo slow atrophic changes. Mercurial or KERATITIS 
KIDNEY, EXAMINATION 
lead plaster will sometimes check a keloid growth. 
Belladonna plaster is useful in alleviating pain, and 
occasionally recourse must be had to morphin. 
Linear scarification and electrolytic puncture have 
been advised. 
KERATITIS.-See Cornea (Diseases). 
KERATOGLOBUS.-Distention and protrusion 
of the cornea. The sclerotic may also become 
distended in severe cases. When so extensive as 
to prevent closure of the lids, it has been called 
buphthalmos. When the distention is transparent, 
regular, and cone-shaped, the apex of the cone 
being the center of the cornea, it is called kerato- 
conus, or conic cornea. When the protrusion is 
opaque or connected with synechia of the iris, it 
is called staphyloma of the cornea, or anterior 
staphyloma. When due to increase in the fluids 
of the eye, with increased tension and uniform 
ectasia, it is called hydrophthalmos. Enlargement 
of the cornea is also called megalocornea. 
KERATOSIS PILARIS.-A cutaneous affection 
characterized by pin-head sized papules situated 
at the mouths of the follicles, and resulting from 
epidermal accumulations or hypertrophy. The 
lesions are grayish, whitish, or blackish in color 
and are found most frequently on the extensor 
surfaces of the extremities. The skin is dry and 
rough, but there is no itching. Infrequent bath- 
ing is believed to be the most common cause. 
Bathing with soft soap and alkaline water, followed 
by vigorous friction, and inunctions of petrolatum 
constitute the treatment. 
KERNIG'S SIGN.-See Cerebrospinal Menin- 
gitis. 
KIDNEY, CONGESTION. Varieties.-(1) Acute 
congestion; (2) chronic congestion. 
The following may be given: 
I). Sweet spirit of niter, 3 vj 
Solution of potassium citrate, 5 ijss 
Simple elixir, 3 iij 
Water, enough to make 3 iv. 
Or- 
I). Citrated caffein, 3 ss 
Water, 3 ij. 
Two teaspoonfuls every 3 or 4 hours. 
Synonyms.-Passive hyperemia; enlargement of 
kidney; passive congestion. 
Etiology.-It is often the result of (1) venous 
stasis, as from disease of the heart, lungs, or liver; 
(2) of pressure of tumor on the renal veins or in the 
region of the kidney. 
Pathology.-The kidney is swollen and of a dark 
brown or purple color. Hemorrhages occur in the 
cortex and beneath the capsule, and often in Bow- 
man's capsules. The tubules may be distended 
with blood. In cases of long standing the kidney 
may become fatty, necrotic, or there may be an 
overgrowth of the connective tissue, and the 
affected organ will become smaller in size and very 
hard. This change is called cyanotic induration. 
Many of the epithelial cells of the tubules are fatty 
and contain oil droplets. 
Symptoms and Clinical Course.-There is dull 
pain or feeling of weight over the loins. The 
urine is dark in color, scanty, and of high specific 
gravity (over 1020). Uric acid is increased; urea 
is normal or slightly increased. In the early 
stages albumin may be detected at certain inter- 
vals; later, it is found constantly. Hyaline casts 
and red blood-corpuscles are often present. There 
may be edema and anasarca. 
The condition may terminate in true nephritis. 
Diagnosis.- 
Chronic Congestion of the Kidney. 
Acute Congestion of the Kidney. 
Synonyms.-Active hyperemia; active conges- 
tion. 
Etiology.-(1) Irritant poisons; (2) surgical 
operations; (3) exposure to the cold and wet; (4) 
pregnancy; (5) eruptive fevers. 
Pathology.-The kidney is slightly enlarged in 
size from an excessive amount of blood, and of a 
dark red color. The renal epithelium shows evi- 
dence of parenchymatous degeneration. 
Symptoms and Clinical Course.-There is dull 
pain over the lumbar region, and pressure over the 
abdominal wall in the region of the kidney may 
occasion pain. The urine is diminished in amount, 
sometimes suppressed, darker in color, of high 
specific gravity, containing albumin, often blood 
and epithelial casts. 
Prognosis depends upon the cause. In most 
cases it is favorable. 
Treatment demands rest in bed and a liquid diet. 
The bowels should be kept active with Rochelle 
or Epsom salts (4 drams). Water may be given 
in abundance to aid in eliminating the effete prod- 
ucts in the kidney. 
Hot baths or vapor baths, by opening the pores 
of the skin, aid the affected renal organs in this 
work. The baths should not be prolonged over 
10 minutes. 
Chronic Congestion of 
the Kidney. 
1. Congestion in other 
organs. 
2. Urine high specific 
gravity. 
3. Transient albumin- 
uria. 
4. Hyaline casts. 
5. Urates and uric 
acid increased. 
Nephritis. 
1. Kidney often first 
affected. 
2. Urine high specific 
gravity at first, 
then gradually 
falling. 
3. Albumin nearly 
always present. 
4. All varieties of 
casts, especially 
granular casts. 
5. Diminished. 
The prognosis and treatment are the same as in 
acute congestion of the kidney. See Nephritis. 
KIDNEY, EXAMINATION. ' Normal Position of 
the Kidneys.-The kidneys are situated in the 
right and left lumbar regions respectively. The 
right is somewhat lower than the left, on account 
of being pushed downward by the liver. The left 
is immediately adjoining the spleen. 
The kidneys extend from the upper border of the 
twelfth dorsal vertebra to the third lumbar verte- 
bra. Posteriorly, they rest upon the lower portion KIDNEY, INFLAMMATION 
KIDNEY, MOVABLE 
of the diaphragm and the fascia covering the 
quadratus lumborum and the psoas magnus mus- 
cles. Anteriorly, the right is covered by the right 
lobe of the liver, the descending portion of the 
duodenum, and the ascending colon; the left one 
has in front the fundus of the stomach, the tail of 
the pancreas, and the descending colon. Both 
kidneys descend about 1/2 of an inch during 
inspiration. 
Physical Examination. Palpation.-The ab- 
dominal walls should be relaxed by drawing up 
the knees when the patient is in the dorsal position. 
Bimanual examination is the best. One hand 
should be placed, posteriorly, over the region of 
the kidney, while the other, anteriorly, makes 
firm pressure downward upon the organ, and by a 
rotatory pressing movement the correct outline is 
determined. 
At times it may be necessary to have the patient 
turn from one side to the other, or even upon the 
abdomen, in making the examination. 
Percussion.-In persons with very thin abdom- 
inal walls percussion may be made anteriorly. 
Usually, however, this method of diagnosis must 
be applied posteriorly, by having the patient lie 
face downward and placing a cushion across the 
abdominal region. The cushion should be of suffi- 
cient height to press the kidneys agaist the mus- 
cles of the back. Strong percussion should be 
made, beginning from below upward, to find the 
lower border of the kidney. To find the external 
border, begin at a point farthest away from the 
organ, gradually moving toward it. It is prac- 
tically impossible to detect the upper margin of 
each kidney, owing to the close relation to liver 
on the right and to spleen on the left. See Kidney 
(Surgery). 
KIDNEY, INFLAMMATION.-See Nephritis, 
Pyelitis 
KIDNEY, INJURIES.-The kidney may be 
wounded, either through the loin or the abdomen; 
in the latter case the peritoneal cavity is opened, 
and probably other organs injured as well. In one 
or two cases prolapse has occurred, the whole organ 
being squeezed out through a wound in the loins. 
The symptoms are the same as in contusion of the 
kidney, with, in addition, those due to the wound. 
The prognosis depends upon the nature of the 
injury; incised wounds heal readily; gunshot in- 
juries, on the other hand, are very likely to be 
followed by suppuration and sloughing; but ex- 
tensive urinary infiltration is not common. The 
lumbar plexus may be torn, the colon opened, 
and even the peritoneal cavity traversed by a 
bullet, without the result being fatal. Fistula, 
however, and serious bladder troubles, phosphatic 
calculus and cystitis, not infrequently make their 
appearance afterward. 
Treatment.-Hemorrhage should be checked 
as soon as possible, and any foreign bodies that 
can be found removed at once; but prolonged 
exploration with a probe in order to find a bullet 
is not advisable. The wound should be left open; 
and, as there is always a tendency for it to be- 
come valvular, a large tube should be introduced 
down to the bottom. Later on, if suppuration 
occurs, free incisions are necessary. In prolapse 
of the kidney, if it is much injured, a ligature 
should be placed around the pedicle and the organ 
removed; in other cases an attempt may be made 
to return it. See Kidney (Surgery). 
KIDNEY IN PREGNANCY.-See Nephritis 
of Pregnancy, Eclampsia. 
KIDNEY, MOVABLE. Synonyms.-Floating 
kidney; wandering kidney ; ectopia renis; neph- 
roptosis. 
Definition.-A condition of the kidney, either 
congenital or acquired, in which the tissues around 
the organ are so lax and the renal vessels so elon- 
gated as to permit the kidney to be moved in 
certain directions, causing a movable tumor in 
the abdomen. 
Etiology.-The kidney is normally held in posi- 
tion by the layer of peritoneum attached to the 
anterior surface of its adipose capsule. In 
movable kidney the adipose tissue in which the 
normal kidney is embedded partly or wholly 
disappears. The renal vessels are in many cases 
abnormally long. Relaxation of the abdominal 
walls from pregnancy or other causes; the use 
of tight corsets or girdles about the waist; violence; 
increased weight of the organ from disease; the 
pressure of tumors growing in the neighborhood 
of the kidney; and the traction of hernias, are all 
causes. The condition may be congenital or 
acquired; more frequently the latter. It is far 
more frequent in women than in men. 
Recent anatomic studies have shown that the 
perirenal fascia contributes materially to the fixa- 
tion of the kidneys. This fascia is a specialized por- 
tion of the retroperitoneal connective tissue, which 
descending from the lower part of the diaphragm, 
splits into two layers above the superior pole 
of the kidney, one passing in front and the other 
behind. The anterior layers blend with one 
another over the lumbar vertebrae. The posterior 
layer on each becomes attached to the vertebrae 
along the inner border of the psoas magnus 
muscle. Excessive development or acquired relax- 
ation of this fascia, is now considered by many 
to be the sole cause of movable kidney. 
Symptoms.-Floating kidney may and often 
does exist without any noticeable symptoms, the 
condition being unknown until accidentally dis- 
covered by the physician while making a physical 
examination of the abdomen. As a rule, however, 
patients experience a heavy, dragging pain in the 
abdomen, aggravated when walking or standing. 
There are also present gastrointestinal symptoms, 
more or less constant, with melancholia, aggra- 
vated by the mental anxiety over the presence of 
a tumor in the abdomen. 
At times, from some unknown or unrecognized 
cause, the movable kidney swells and becomes 
very sensitive to the touch, and migrates a con- 
siderable distance from its normal position. 
Such an occurrence aggravates all the symptoms 
mentioned. This condition has been ascribed 
to a twisting of the ureter and consequent reten- 
tion of the urine in the pelvis of the kidney, or to 
localized peritonitis, or to a partial strangulation 
of the kidney from compression or twisting of its KIDNEY, PAIN 
blood-vessels. Hysteric symptoms are frequently 
observed in women suffering from wandering 
kidney. 
Diagnosis.-The possibility of dislocation of the 
kidney is to be borne in mind in determining the 
nature of obscure tumors within the abdomen. 
Flint based the recognition of this variety of ab- 
dominal tumor on the following diagnostic points: 
" It is situated in the hypochondriac region. It has 
the size and shape of the normal kidney, and this 
may be determinable by palpation, which is most 
advantageously employed by placing one hand 
over the lumbar region and the other in front on 
the abdominal walls, and then making counter- 
pressure from one hand to the other. It is gener- 
ally movable, and in some cases the organ can be 
restored to its proper situation." Other tumors 
are to be excluded by the absence of their diag- 
nostic characters. 
It is a rare occurrence to have a fatal termina- 
tion from movable kidney per se. 
Treatment is symptomatic. Some of the in- 
convenience, and sometimes the suffering, attend- 
ing movable kidney may be lessened by means of an 
abdominal bandage, belt, or supporter. Stengel 
proposes two plans of treatment: (1) Overfeeding, 
to restore the necessary perirenal fat-which, 
however, was not successful; (2) artificial support 
by an abdominal belt and kidney-shaped pad so 
constructed as to exert pressure upward, back- 
ward, and to the right, instead of directly upward, 
as is usual. If attacks of pain and swelling occur, 
the patient should be placed in bed, have hot appli- 
cations over the abdomen, opiates ordered, and 
attempts made to replace the organ. Extirpa- 
tion of a movable kidney has been successfully 
performed a number of times. Nephrorrhaphy is 
an operation for fixation of the kidney to the 
parietes by means of sutures. See Kidney (Sur- 
gery). 
KIDNEY, PAIN.-There is great disposition 
among the laity to attribute any pain in the loins 
to kidney-disease. Very often lumbar neuralgia, 
lumbago, or muscular rheumatism is the source of 
the trouble. Chronic nephritis is not generally 
associated with localized pain. Acute nephritis 
may be accompanied by severe pain in the region 
of the kidney. Chronic renal congestion is ac- 
companied by dull pain and a feeling of weight 
over the loin. Movable kidney may produce 
similar symptoms. 
Renal colic, due to the passage of a calculus 
from the pelvis of the kidney through the ureter, 
is the most common cause of pains in the kidney. 
The history of previous attacks of a similar char- 
acter, the radiation of the pain downward into the 
groin and testicle, or to the end of the penis, aid in 
deciding the diagnosis; while the presence of blood 
in the urine, the irritable bladder, and the intense 
agony in the paroxysm, in contrast to the remis- 
sions, and the sudden onset, still further point to 
this condition. These symptoms are not, however, 
always present in sufficient degree or in association 
to make the diagnosis easy, and the absence of one 
prominent sign may seriously impair its certainty. 
Somewhat similar pains arise from pyelitis with 
possible nephritic abscess, from neuralgia of the 
kidney or the tissues near by, from nerve pains due 
to spinal caries or irritation, and, more rarely, 
from tumors adjacent to or in the gland, or from 
aneurysm of vessels: as, for example, aneurysm 
of one of the branches of the mesenteric artery. 
A calculus embedded in the kidney may be found, 
or excessive deposits of oxalic acid or other 
crystals, manifesting themselves in gouty kidney, 
or, finally, aortic valvular disease. Chronic pain 
in the kidney is ascribed to slight injury, and is 
said to be commonly met with in young women 
who endeavor while wearing corsets to take 
violent physical exercise. 
The presence of pyelitis rarely produces great 
pain, and the appearances of the urine point clearly 
to the cause of the discomfort, though if the 
attacks are sudden in onset, the cause may be 
calculus in the pelvis of the kidney, surrounded 
by septic changes. The failure of health and the 
possible febrile movements and chills still further 
point to pyelitis. So, too, nephritic abscess is 
accompanied by so much systemic disturbance in 
many cases as to make the diagnosis clear. 
The presence of spinal tenderness on pressure or 
motion in the dorsal or lumbar regions, and the 
history of spinal irritation or disease, decides this 
as the cause of the pain. The discovery of 
aneurysm of any of the abdominal vessels may be 
impossible, unless it is large enough to manifest 
itself through the viscera or abdominal wall on 
palpation. 
The diagnosis of stone embedded in the kidney is 
very difficult and uncertain, but the onset of an 
attack of renal pain arising from oxaluria or an 
attack of gout is usually bilateral, and is associated 
with a scanty urine of high specific gravity, and 
with much lumbar soreness. A gouty history or 
that of having eaten large amounts of oxalic-acid 
bearing foods, such as pears, tomatoes, and cab- 
bage, may be recognized as the predisposing causes 
of attack. 
Fenwick asserts that there are two great groups 
of renal stones, and that in each class characteristic 
pain may be felt. In the cortical stones the pain 
is fixed and continuous, and is liable to exacerba- 
tion on movement, but does not depend so much 
upon changes in the diet. On the other hand, 
pelvic stones cause obstruction and colic, the pain 
radiating down into the groin and testicle, while 
the urine becomes bloody, purulent, or scanty. 
Fenwick also believes that the posture of the pa- 
tient in bed is typical. In 9 out of 12 cases his 
patients could sleep only on the affected side. 
Cortical stones, in his opinion, never cease to give 
discomfort, but pelvic stones may become em- 
bedded, and the patient go for long periods of 
time free from any discomfort. 
Many years ago attention was called to the fact 
that aortic valvular disease often caused pain to be 
radiated into the hypochondrium. Ralfe thinks 
that aching kidney is often due to unrecognized 
trauma. He has known of cases of young women 
who, by wearing tight corsets while playing tennis 
or other violent games, have so bruised the right 
kidney by some sudden and violent movement as 
KIDNEY, PAIN KIDNEY, STONE 
KIDNEY, SURGERY 
to suffer seriously for days afterward. Again, 
Ralfe asserts that sharp renal pain sometimes arises 
in cases of obstinate constipation, in which are ac- 
cumulated in the colon hard scybalous masses which, 
by their pressure, produce reflex irritation and pain. 
KIDNEY, STONE (Nephrolithiasis; Renal Calcu- 
lus).-A condition in which concretions or calculi 
form in the kidney structure, pelvis of kidney, or 
ureter. 
Etiology.-(1) Early infancy; (2) gout; (3) old 
age; (4) lithemia. 
Pathology.-Renal calculi may be composed 
principally of uric acid, oxalate of lime, or phos- 
phates of calcium, magnesium, and potassium. 
They may be of different sizes and shapes, some 
having pointed edges, giving rise to excruciating 
pain as they pass into the ureter. If the stone 
forms in the pelvis of the kidney or the ureter, 
some foreign body, such as a blood-clot, generally 
acts as a nucleus. 
Phosphatic stones are whitish or grayish-white, 
and soft in consistence. They are the largest 
variety. The uric acid stones are dark red or 
reddish-brown in color, very hard, and often 
pyramidal in shape. 
Symptoms and Clinical Course.-In some cases 
no symptoriis arise. The most common symptom 
is pain in the region of the kidney, aggravated by 
exercise or sudden jarring of the body. If the 
ureter is totally occluded, hydronephrosis occurs. 
When the calculus passes into the ureter, true renal 
colic ensues. 
This begins with a distinct chill, blueness of the 
extremities, and agonizing pains in the lumbar 
region, radiating toward the umbilicus, down the 
ureters, and into the testicles, which may become 
retracted. Nausea and vomiting come on, ac- 
companied by increased micturition, a feeble 
pulse, and symptoms of collapse. Occasionally 
after the paroxysm has ended, blood may be 
detected in the urine, and in some cases the stone 
is passed by the urethra. 
Diagnosis.-(See also Colic.) 
Prognosis is guardedly favorable. 
Treatment.-For the acute attack of renal colic 
morphin (1/4 of a grain) and atropin (1/125 of a 
grain) should be given at once, and repeated in 
2 hours, if necessary, to relieve the extreme agony 
of the patient. Hot flannel cloths, stupes, or 
poultices should then be placed over the affected 
area, and may aid in rendering the patient com- 
fortable. 
In the constantly recurring attacks, in which the 
symptoms are not so violent, much may be done 
by means of dieting. Meats, tea, and coffee should 
be greatly restricted; alcohol and tobacco should 
be avoided. Milk, soups, fruits, vegetables, eggs, 
and an easily assimilable diet is best. 
Bathing in lukewarm water 2 or 3 times a week, 
followed by massage, will stimulate the skin and 
keep the circulation active. 
The bowels should never be allowed to become 
constipated, and saline purgatives, such as Ro- 
chelle salts (4 drams), Epsom salts (4 drams), and 
Carlsbad salts (1 to 2 drams), may be given. 
Alkaline diuretics may be valuable. 
1$. Potassium acetate, 
Potassium bicar- 
bonate, 
Potassium citrate, 
each, 5 ij 
Fluidextract of triticum, 5 iv 
Water, enough to make, 5 iv. 
One teaspoonful every 3 or 4 hours. 
Failing to secure relief by medicinal measures, 
surgical interference should be effected and the 
stone removed. See Kidney (Surgery). 
KIDNEY, SURGERY.-Although the kidney had 
occasionally been the subject of surgical operation 
in early times, premeditated kidney surgery may 
be said to have begun with Gustav Simon's success- 
ful extirpation of the one kidney for ureterouterine 
abdominal fistula in 1869. He did this operation 
after a demonstration of the healthy condition of 
the other kidney, and after a series of experiments 
on dogs showing that the removal of one kidney 
was a practicable procedure. Two years later 
Simon removed another kidney for calculi and 
suppurative pyelitis. The patient unfortunately 
died of pyemia on the twenty-first day after the 
operation. At that time surgeons were unac- 
quainted with antiseptic methods. Since the 
publication of Simon's work on the surgery of the 
kidney, in 1871 ("Chirurgie der Nieren" Erlangen), 
the methods of diagnosis have been so much im- 
proved in scope and precision by the ureter cysto- 
scope, by the X-ray photographs, and by the 
study of clinical and pathologic material that the 
radical operations of 20 years ago have given way 
to partial nephrectomies, nephrotomies, and vari- 
ous reparative operations on the ureter and pelvis 
of the kidney. 
Location.-The kidneys are located in the back 
in such a position that a little more than one-half 
of each is exposed below the last rib. The hilus 
or root of the kidney, into which pass the renal 
arteries and out of which pass the renal veins and 
the ureters, is directed toward the vertebrae and 
a little downward, so that a line passing longi- 
Renal Colic. 
Intestinal 
Colic. 
Biliary Colic. 
1. Sudden onset.. .. 
2. Chill, subnormal 
temperature, col- 
lapse. 
3. Pain begins in re- 
gion of affected 
kidney, radiating 
down thigh and 
testicle,which may 
retract. 
4. Micturition fre- 
quent. 
5. Blood in urine... 
6. Presence of stone 
in urine. 
7. Pain continues for 
a day or two in 
affected ureter. 
1. Premonitory 
symptoms, such 
as nausea, bor- 
borygmi. 
2. No chill 
1. Sudden onset. 
2. Chill and collapse, 
followed by jaun- 
dice. 
3. Pain begins in 
region of stomach 
on right side, ra- 
diating toward um- 
bilicus. 
4. Micturition nor- 
mal ; urine con- 
tains bile. 
5. No blood in urine. 
6. Stone often pass- 
ed in feces; stools 
devoid of bile. 
7. Pain uniform over 
abdomen. 
3. Pain begins in 
abdominal re- 
gion, radiating 
toward umbili- 
cus. 
4. M i c t u r i tion 
normal 
5. No blood in 
urine. 
6. No stone in 
urine. 
7. Pain uniform 
over abdomen. KIDNEY, SURGERY 
KIDNEY, SURGERY 
tudinally through the middle of one kidney 
from pole to pole would meet a similar line, pass- 
ing in the same way through the opposite kidney, 
somewhere in the region of the body of the sixth 
dorsal vertebra. 
The ureters are small tubes, 30 cm. long, the 
walls composed of 2 layers of muscle and a thick 
layer of mucous membrane. They are supplied 
with blood-vessels from the kidney and bladder 
and from the adjoining connective tissue. The 
ureters are not of uniform caliber throughout 
their length, but are funnel-shaped at the kidney, 
and meet with a constriction as they pass over the 
brim of the pelvis, and another upon entering the 
bladder. The pelvis of the kidney is continuous 
with the ureter, and is connected with the several 
calices by infundibula. The relation of these 
parts is not uniform. 
The kidney may be approached through an in- 
cision 4 to 6 inches long along the outer border of 
the quadratus lumborum muscle, or it may be 
reached through a laparotomy wound. The 
lower 3 cm. of the ureter may be approached in 
women by way of the vagina, and the rest of the 
ureter can be easily examined, both in men and 
women, through a laparotomy wound. 
Operations.-Aspiration of the kidney may be 
performed either for the purpose of diagnosing a 
renal swelling, or for the relief of such affections as 
hydronephrosis, pyonephrosis, or hydatid or blood 
cysts. It should be done with the ordinary pre- 
cautions, any prominent or fluctuating spot being 
chosen for the puncture. 
Nephrotomy consists in making an incision into 
the kidney for the purpose of evacuating and 
draining the fluid or pus in the case of hydronephro- 
sis, pyonephrosis, hydatid cyst, abscess, etc. The 
tumor may be exposed by the lumbar or lateral 
incision, as described in nephrectomy. An inci- 
sion is made into the kidney, the fluid allowed to 
run out, the wound thoroughly irrigated with 
some antiseptic solution and insufflated with iodo- 
form, a large-sized drainage-tube inserted into 
it, and voluminous dressings of absorbent cotton 
and the like applied to receive the subsequent 
discharges. 
Nephrolithotomy consists in cutting into a kid- 
ney for the purpose of extracting a calculus. The 
kidney may be exposed either by the lumbar or 
lateral incision, as described in nephrectomy. If 
a stone is felt, an incision should be carefully made 
over it, the finger or forceps introduced, and the 
stone extracted. If one cannot be felt, a needle 
should be thrust into the kidney at several situa- 
tions, and, this failing, an incision should be made 
into it, and the finger and a probe introduced to 
search for stone. A drainage-tube should be 
placed in the wound, and an antiseptic and absor- 
bent dressing applied. The urine will at first escape 
through the wound, but will cease to do so, as a 
rule, after a longer or shorter interval. 
Nephrectomy, or removal of the kidney, may be 
done without opening the peritoneum, either by a 
lumbar or lateral incision, or through the peritoneal 
cavity, the incision being then made either in the 
linea alba or linea semilunaris. 
The Extraperitoneal Operation.-If the incision is 
made in the lumbar region, it may be vertical, T- 
shaped, or oblique, like that of colotomy. If the 
lateral incision is chosen, it should be made ob- 
liquely from near the tip of the last rib toward the 
anterior superior spine of the ilium. Its advan- 
tages are that it combines the facilities of the intra- 
peritoneal and the greater safety of the lumbar 
incision, as it does not involve opening the peri- 
toneal cavity. The kidney having been exposed 
by any of these incisions, the capsule should be 
opened, the finger introduced, and the kidney 
enucleated from its capsule; the renal artery and 
vein should then be securely tied with a silk 
ligature passed round them by an aneurysm needle, 
and the ureter separated in a similar way. The 
kidney is removed by cutting through the pedicle 
with scissors, and the wound drained and dressed 
antiseptically. 
The Intraperitoneal Operation.-This consists in 
opening the peritoneal cavity by one of the incisions 
mentioned above, drawing the intestines aside, 
and then exposing the kidney by cutting through 
the peritoneum in front of it, external to the colon. 
The vessels are then tied separately, the kidney 
removed, and the peritoneum united, the same 
precautions being adopted as after an ovariotomy. 
A drainage-tube is passed by some surgeons through 
a counter opening in the loin, and the end of the 
ureter brought out of the wound. 
The dangers of nephrectomy are: (1) Severe 
shock; (2) excessive hemorrhage; (3) suppression 
of urine from disease or absence of the opposite 
kidney; (4) peritonitis from wounding the peri- 
toneum; (5) laceration of the colon; (6) inclusion 
of the vena cava in the ligature of the pedicle and 
injury of the duodenum in operating on the right 
side. 
Nephrorrhaphy is an operation for fixing a floating 
or movable kidney by exposing the kidney in the 
loin and attaching it with sutures to the parietes. 
It should only be done when there is intense pain 
and constant suffering which palliatives have 
failed to relieve. 
Surgery of the kidney may be necessary for (1) 
Congenital malformation, (2) for injury of the 
kidney, (3) for disease of the kidney, or (4) for 
deformity of the kidney or ureter, the result of 
injury or disease. 
When a kidney is found abnormally placed in 
the pelvis of a woman likely to bear children, it 
must be removed to make parturition possible. 
When a congenitally cystic kidney grows after 
birth so as to interfere with the development of 
the child, it must be removed. When a ureter con- 
genitally misplaced discharges urine into the 
vagina or urethra, the ureter must be implanted 
into its proper place, or the kidney tributary to it 
must be removed. When there is a congenital 
deformity of the ureter or kidney which results in 
complete or partial hydronephrosis, the deformity 
must be corrected or the whole kidney or part of 
it must be removed. 
There are two sorts of injury of the kidney re- 
quiring surgical treatment. The kidney is some- 
times driven out of place by a blow, a fall, or a slow KIDNEY, SURGERY 
KIDNEY, SURGERY 
compression, as between two freight cars. A 
suddenly displaced kidney without rupture has 
given rise to: (1) No symptom except pain; (2) 
to pain and obstruction of the ureter by torsion 
or kinking, and the rise of temperature attend- 
ant; and (3) to pain, tumor, and bloody urine, or 
these symptoms with a perirenal or abdominal 
hematoma. 
The kidney is sometimes ruptured by the direct 
action of a blow, a fall, or a broken twelfth rib. 
The result is a Jiemorrhage either outward into the 
perirenal tissues or inward into the pelvis of the 
kidney or one of the calices; in the latter case 
there is bloody urine. Sometimes the rupture 
extends entirely through the cortex, and both 
blood and urine are then found in the perirenal 
tissue. In children the perirenal peritoneum is 
often ruptured by the same insult that ruptures 
the kidney. Then the blood and urine are extrav- 
asated into the general peritoneal cavity. The 
perirenal hematoma, especially if mixed with 
urine, is almost sure to become infected and pro- 
duce a perirenal abscess if the patient lives so 
long. The patient is likely, however, to die of 
hemorrhage. This is sure to be the case when 
the renal vein itself or one of its larger branches 
is ruptured. Death comes on in the course of 
24 or 48 hours. 
When the kidney has been displaced, either 
slowly (floating kidney) or suddenly, and great 
pain persists, either with or without rise of temper- 
ature, indicating pyonephrosis, the kidney should 
be approached by an incision beginning on the 
outer margin of the overlying quadratus lumborum 
muscle just below the edge of the last rib, and 
extending downward to the crest of the ilium and 
then curved outward for about half a finger's 
length. Through this opening the kidney should 
be carefully reached (by dividing the perirenal fat 
with dull instruments or with the fingers) and 
carefully drawn out through the fat, and even out 
of the depressed edges of the wound. It will stay 
in the wound if it is slightly twisted like a button. 
Here it can be examined. The ureter should be 
found on the lower side. There should be no 
blood. The kidney is then allowed to sink back 
under the skin, but should be held within the 
muscular wound by a strip of gauze passed under 
the upper pole. The skin and muscle should then 
be partially coapted with sterile silk or silver 
wire. The gauze should be carefully and slowly 
removed about the fourth day, when the sutures 
are removed, and the resulting wound allowed to 
close slowly, with a diminishing iodoform gauze 
tampon. 
When an injury of the kidney results in a large 
hematoma, without bloody urine, without symp- 
toms of severe hemorrhage, and without any rise 
of temperature indicative of sepsis, it is enough to 
keep the patient in bed, apply cold, and wait. 
When, however, a perirenal hematoma is accom- 
panied by symptoms of gradually increasing 
anemia, rapid pulse, thirst, low temperature, 
pallor, and delirium, the kidney must be ap- 
proached at once by the method mentioned and 
the ruptured kidney tamponed, or the bleeding 
vein compressed by a forceps left on for 24 or 48 
hours. When the ruptured kidney cortex is tam- 
poned with iodoform gauze, it may sometimes be 
necessary to pass one or two large silk sutures 
through the kidney from side to side to hold the 
tampon in the rupture. In such a case it is neces- 
sary to drain the perirenal space for a week or 
more. 
When the cortex of the kidney is completely 
ruptured and the hematoma contains urine as well 
as blood, the treatment mentioned is imperative, 
but the drainage must be continued much longer. 
When a large or small hematoma becomes 
infected after weeks or months, it gives rise to sep- 
sis and abscess formation-the so-called peri- 
renal abscess-and it must be opened and drained. 
The incision need not be quite so extensive as that 
described, but should be in the same line, and 3 
inches or more in length. Perirenal abscess often 
occurs without the history of injury; the treatment 
is the same. 
The diseases of the kidney for which surgical 
treatment is necessary may be grouped under three 
heads: (1) Pus-diseases; (2) tubercular diseases; 
(3) tumors. 
Pus microbes may reach the pelvis of the kidney 
by way of the urethra, bladder, and ureter, and, 
having injured the ureter by forming granulations 
and obstructing the outflow of urine, pyonephrosis 
results. The pus, which had probably been 
noticed in the urine, stops; chills and fever come 
on; a large tumor, at last, after weeks or months, 
appears in the lumbar and outer abdominal region. 
In such a case the cortex of the kidney becomes 
very much thinned out, and its secretion stopped. 
The heart is usually hypertrophied. The treat- 
ment is obvious. The dilated kidney should be at 
once carefully opened, as in the case of, and in the 
same place as, rupture, even though it seems to 
"point" in front. Drainage must be kept up, 
and, if necessary, a subsequent operation done to 
remedy any defect in the ureter. 
Pus infection sometimes reaches the kidney, 
especially in the course of typhoid or other infec- 
tious diseases, by way of the circulating blood, pro- 
ducing an infarct, and afterward an abscess, which 
may rupture outwardly and result in a perirenal 
abscess, or into one of the calices and produce a 
pyonephrosis. Multiple abscess of the kidney 
with pyonephrosis follows infection of the urethra, 
bladder, and ureter, especially in certain cases of 
gonorrhea and in catheterization during confine- 
ment, and as a part of a general pyemia. In the 
former case nothing avails except the complete 
and prompt removal of the whole kidney, while in 
the latter case we are helpless to offer any relief at 
all. 
In some persons, in certain conditions of diges- 
tion and elimination, and in certain locations the 
crystallizable matter of the urine is precipitated in 
the renal tubules, in the calices, or in the pelvis of 
the kidney. When these crystals are small, they 
pass off in the urine without being noticed. Some- 
times they remain behind and furnish centers 
about which, according to well-known principles 
of crystallization, further deposits take place. KIDNEY, SURGERY 
KIDNEY, SURGERY 
Such masses of crystals are called renal calculi 
when they are found in the calices or pelvis of the 
kidney, ureteral calculi when they are found in the 
ureter, and vesical calculi when they are found in 
the bladder. They often remain unrecognized for 
years, and grow to a large size (2 to 5 ounces). 
They make themselves known by terrible pain 
whenever they pass down the urinary tract or 
obstruct the flow of urine. Small stones less than 
a centimeter in diameter pass down the ureter in 
the course of 10 to 40 hours of great agony, and 
are then passed out of the bladder through the 
urethra with relative ease, especially if the urethra 
is cocainized and dilated with a large sound. The 
patient should take such a position as to bring 
the stone into the urethra at the beginning of 
emptying a full bladder. When a larger or 
smaller stone is retained in the bladder, it grows, 
and sooner or later gives rise to the symptoms of 
vesical calculi. 
Even a very small stone passing down the ureter 
may give rise to unendurable pain, coming on in 
paroxysms at intervals of a few minutes, or it may 
pass off after many paroxysms weeks or months 
apart. Sometimes the passage of quite a large 
stone through the ureter is unnoticed or produces 
only a dull pain in the side and back. The pain 
is, however, usually worse at the beginning of the 
ureter, at the constriction at the brim of the pelvis, 
and at the perforation of the bladder. The pain 
is often referred to the inside of the thigh, to the 
testicle, or to the labia, but as it grows severe it 
settles in the side and is accompanied by tender- 
ness over the ureter and kidney. The treatment 
is warm baths, hot applications, and large doses 
of morphin. Vigorous catharsis and a liberal 
liquid diet, with rest in bed, must be prescribed. 
If the pain continues longer than 2 days, and the 
temperature rises more than a degree or two, the 
region of the stone has probably become the site 
of infection. 
One of the most serious consequences of calculi 
in the urinary tract is the almost inevitable micro- 
bic pus infection which sooner or later surrounds 
the stone. Suppuration about the stone produces 
pyonephrosis, either complete or partial. When 
the pus stops discharging itself through the blad- 
der, either because the stone acts as a valve in the 
ureter or because the ureter has been deformed 
and obstructed, the kidney becomes distended 
and the patient has all the symptoms of sepsis. 
Then the kidney must be approached as described 
above, the stone or stones removed, and the pelvis 
of the kidney drained. A subsequent operation 
may be required to repair any remaining obstruc- 
tion of the ureter. 
The removal of a stone in the ureter requires un- 
usual operative procedure, which can be undertaken 
only on very exact diagnosis and under most 
favorable circumstances. At the bladder end of 
the ureter in women the stone may sometimes be 
easily helped into the bladder by simple digital 
manipulation through the vagina or rectum. 
Tubercular infection reaches the kidney through 
the circulation, when it produces a double-sided 
and inoperable miliary tuberculosis or a tubercular 
disease confined to a single focus of infection, 
primarily through the external genitals, the urethra, 
prostate, bladder, and ureter. Primary renal 
tuberculosis, the so-called renal phthisis, is a 
little less frequent than renal tuberculosis, going 
on after tubercular epididymitis, tubercular pros- 
tatitis, and tubercular cystitis. This condition 
is slow in its onset, insidious in its progress, and, 
after both kidneys are attacked, absolutely un- 
favorable in prognosis. The diagnosis is made by 
discovering tubercular nodules in the epididymis, 
seminal vessels, and prostate, by recognizing tuber- 
cular bacilli in the semen or urine, by discovering 
tubercular ulcers of the bladder, and by finding 
the ureter from the tubercular kidney enlarged. 
The crucial test is made by catheterizing the ureters 
and finding tubercle bacilli on the one side, with 
diminished urine, and healthy and increased urine 
on the other side. The treatment for tuberculosis 
of the kidney is removal of the tubercular kidney 
and ureter and all peripheral tubercular tissue, the 
seminal vesicles, the prostate, the testicle, and the 
cord. 
Hydronephrosis. - Complete hydronephrosis is 
due to partial obstruction of the ureter. Its treat- 
ment is repair of the ureter, a difficult and com- 
plex operation. Partial hydronephrosis is due to 
partial obstruction of one or more of the infundib- 
ula. It may be treated by exposing the kidney, 
as described before, and cutting away with the 
scissors the wall of the cyst and destroying the 
remaining mucous membrane with a solution of 
zinc chlorid 1:40. 
The adrenal tumors of the kidney usually grow 
in adults from remnant of adrenal tissue left be- 
tween the lobules of the kidney. They do not, 
as a rule, invade the kidney substance, but dis- 
place it. They can generally be enucleated, and 
after such removal they show no tendency to recur. 
When they are of large size, they are likely to 
break down, and extensive hemorrhages occur in 
the tumor substance, sometimes invading the 
surrounding tissues. If one of these adrenal 
tumors growing near the pelvis of the kidney 
breaks through into the pelvis itself, bloody 
urine follows immediately. These tumors some- 
times produce the normal secretion of the adrenal 
gland in too great a quantity. Then the patient's 
heart is slowed, his capillaries contracted, and his 
skin blanched. He has severe headaches. His 
arteries rapidly undergo sclerosis, and apoplexy 
is apt to occur even in the young. Some adrenal 
tumors show a tendency to metastasis in which 
the lungs and bones are usually conspicuous. 
These tumors should be enucleated from the 
kidney when possible; when this procedure is 
impossible, a part of the kidney should be removed. 
Malignant tumors in the adult are usually hyper- 
nephromas, or carcinomas. The former are the 
more common. Many tumors formerly supposed 
to be carcinomas were undoubtedly hypernephro- 
mas. Sarcomas are rare. In children they may 
attain a very large size in a short time. Second- 
ary or metastatic carcinomas of the kidney are not 
fit for surgical treatment. In primary carcinoma 
the right kidney is a little more frequently at- KIDNEY, SURGERY 
KNEE-JOINT, INJURIES 
tacked than the left. Men are more often affected 
than women. Carcinoma sometimes follows long- 
neglected stone in the kidney and pyonephrosis. 
Primary carcinoma appears about the age of 50 to 
60. Less than 1 percent of all primary carcinomas 
appear in the kidney. The diagnosis is made by 
the appearance of blood in the urine, pain in one 
side, tenderness and tumor in the region of the kid- 
ney, loss of weight for several months, and slight 
cachexia. Some latent cases show no blood in the 
urine and no tumor: say, one-third of all. Some 
cases show no tumor, but exhibit more or less fre- 
quent hematuria: say, one-tenth. Perhaps one- 
third of all cases exhibit both bloody urine and 
palpable tumor (these are the ideal cases for diag- 
nosis), while the remainder show' palpable tumor 
but no hematuria. The crucial test is the dis- 
covery of shreds of carcinoma tissue in the bloody 
urine. The tumor is usually nodular, attached to 
the kidney, moving with respiration. When ob- 
struction results from clots in the ureter, the 
symptoms are like those in the passage of small 
renal stones. The blood-clot then resembles a 
black earthworm of enormous length. 
Every case of hypernephroma and primary 
carcinoma of the kidney should be treated by 
complete removal of the affected kidney after the 
health and competency of the opposite kidney have 
been demonstrated. 
The diagnosis of disease of the kidney is made 
by palpation, which in thin persons will discover 
the normal kidney and any tumor of considerable 
size; by percussion, which will sometimes discover 
the normal and always the greatly enlarged kidney; 
by urinary examination; by exploratory puncture; 
by photography or fluoroscopy with the X-rays, 
which will often discover stone; and by incision 
and direct palpation. 
Summary.-The following adages should be con- 
sidered in all cases requiring operations on the 
kidney: 
1. One healthy kidney should be demonstrated 
by catheterizing the ureters before any considerable 
operation is undertaken on the opposite organ. 
2. The kidney should be extirpated only for 
malignant disease, for tuberculosis, for rupture 
of the renal artery or vein, for irreparable loss of 
the ureter and for pyonephrosis when the kidney 
is riddled with multiple foci of suppuration, for 
the removal of which a nephrotomy has proved 
inadequate. Even a small portion of cortical 
substance should be left, as it shows great repro- 
ductive power. 
3. In pyonephrosis the abscess should be freely 
opened and drained, and all reparative procedures 
on the obstructed ureter should be left to a sub- 
sequent operation. 
4. An operation on a healthy kidney is more 
likely to precipitate an acute nephritis in the op- 
posite kidney than a much more severe operation 
on a sick kidney. 
5. The emergency operations on the kidney are 
for hemorrhage about the kidney in rupture of 
the kidney or rupture of the renal vein, torsion of 
the ureter in wandering kidney, and pyonephrosis. 
6. Chloroform is the best anesthetic for kidney 
operations, but a pyonephrosis may be opened 
with Schleich's local anesthesia or with the use 
of ethyl chlorid spray. 
7. Hypertrophy of the heart is usually observed 
in-any disease impairing the function of the kidney. 
8. Renal hematuria from an apparently healthy 
kidney has been repeatedly observed. 
9. Operations on the kidney by the abdominal 
way are much more dangerous to the patient than 
similar operations by the lumbar incision. 
10. Hydronephrosis is the result of partial ob- 
struction of the ureter. Complete obstruction with- 
out infection results in atrophy and disappearance 
of the kidney. 
11. Percussion is of little use in diagnosis. 
12. Only in thin people can the lower pole of 
the normal kidney be palpated, and then only 
on inspiration and expiration. 
13. Auscultatory percussion is of much value. 
See Kidney (Stone, Movable), Nephritis, Pye- 
litis, etc. 
KINO.-The inspissated juice of Pterocarpus 
marsupium, found in India, and similar in action 
to tannic acid. It contains 75 percent of a variety 
of tannin named kinotannic add, which gives a 
greenish precipitate with persalts of iron; also a 
crystalline, neutral substance, kinoin, and kino- 
red, gum, pectin, etc. Dose, 5 to 10 grains. It is 
used mainly as a constituent of gargles and diar- 
rhea mixtures. The tincture in dram doses is one 
of the best remedies for the diarrhea which results 
from the disuse of opium or morphin. K., Tinct., 
5 percent of the drug. Dose, 1/2 to 2 drams. 
KNEE-JERK.-See Jerk, Reflexes, Nervous 
Diseases (Examination), Locomotor Ataxia. 
KNEE-JOINT, DISEASE.-See Joints 
(Diseases), Excision of Joints. 
KNEE-JOINT, INJURIES.-Fracture of the 
patella is a frequent injury due to direct violence, 
producing an oblique or stellar fracture; or to in- 
direct violence, sudden muscular traction of the 
quadriceps, producing transverse fracture (traction 
fracture). 
Transverse and Vertical Fracture of the Patella. 
-(Spencer and Gask.) 
Fracture the result of direct violence is seldom 
accompanied by the same degree of diastasis of 
fragments as fracture the result of muscular con- 
traction, in which there frequently occurs an 
extensive laceration of the aponeurotic layers 
passing alongside the patella; without this lacer- 
ation wide separation of the fragments cannot 
occur. 
The patella is fully inclosed in the capsule of the 
joint, and hemorrhage is into the joint. Excep- KNEE-JOINT, INJURIES 
KNEE-JOINT, INJURIES 
tionally, this may be excessive and distend the 
capsule. 
When only a small piece at the edge of the pa- 
tella is separated, and if the periosteal covering re- 
mains intact, the diagnosis may be difficult and 
doubtful. But when the fracture is transverse 
and is accompanied by some diastasis of the frag- 
ments, the diagnosis lies immediately at hand. 
This fracture is peculiar in that there may result 
a very good and useful limb, with comparatively 
wide separation of 
the fragments and 
fibrous union entirely, 
while sometimes well- 
placed fragments 
united by bony union 
occasion a permanent 
impairment function- 
ally. 
Treatment. - In 
fractures from direct 
violence, when there 
is likely to be little 
or no separation, treat- 
ment is comparatively 
easy,consisting in fixa- 
tion by means of a 
posterior splint and 
roller bandage. The 
danger here is not 
nonunion, but anky- 
losis. If a distending 
hemorrhage has oc- 
curred into the joint, 
it should be removed 
by aspiration. Mas- 
sage of the quadri- 
ceps should be prac- 
tised almost daily, 
and passive motion 
begun as early as the 
hird week. At the 
end of 6 weeks dressings can be discarded and the 
patient permitted to go about. 
It is in the transverse fracture, the result of 
muscular traction, that the serious difficulty oc- 
curs. Here the fragments are likely to be widely 
separated, owing to the tearing of the lateral apon- 
eurotic layers along the sides of the patella. The 
aponeurosis covering the patella becomes first very 
much stretched, and when it finally tears, a re- 
tracted fringe projects between the fragments. 
This fringe sometimes prevents an osseous union, 
even when the fragments can be closely apposed. 
Above all, it is the condition of the quadriceps 
extensor muscle which most demands attention. 
Even when comparatively good union is attained, 
a useless limb may result because of the atrophic 
condition of the muscle which has occurred as the 
direct result of the treatment that brought the 
fragments close together and permitted a good 
union. To effect apposition of the fragments it 
is necessary to practically paralyze the muscle 
with the roller bandage. The nutritive disturb- 
ance thus brought about, together with the 
atrophy resulting from the prolonged inactivity of 
the muscle, leaves the muscle in a crippled condi- 
tion, from which it does not recover. This fact 
has lead to the treatment of this condition by 
daily massage alone (kneading and tapotement), 
the effort being made at the same time to bring 
the fragments nearer together. Very good func- 
tional results are reported as a result of this treat- 
ment. A better plan of conservative treatment 
is to combine this valuable method with the effort 
to approximate the fragments directly. This is 
accomplished by means of a posterior splint, ap- 
plied with the leg extended and the thigh flexed, 
so relaxing the quadriceps. Straps of adhesive 
plaster now catch the upper and lower fragments, 
cross each other, and are stuck fast over the pos- 
terior aspect of the splint, so pulling the lower 
fragment up and the upper fragment down. A 
circular strip over the fragments may be found 
necessary to keep them from tipping. A figure- 
of-eight bandage may reinforce these straps. 
The quadriceps is now to be massaged daily, 
chiefly from above downward, seeking thus to 
bring down the upper fragment. Complete failure 
of union and adhesion of the upper fragment to 
the anterior surface of the thigh are rare and, of 
course, very unfavorable occurrences. 
Subcutaneous suture by means of wire, tendon, 
or silk is recommended; but of operative measures 
only the open bone suture is to be advised. Chro- 
micized catgut answers this purpose well. The 
sutures need not penetrate the fragments of bone; 
by being passed through the aponeurotic layers 
over and to the sides of the patella, they are able 
to bring the fragments in apposition. This pro- 
cedure is only to be attempted by a skilled surgeon, 
as the knee-joint is necessarily opened, and the 
occurrence of sepsis here may be fatal either to the 
usefulness of the joint or to the life of the patient. 
When this operation is undertaken, it is advisable 
to use rubber gloves, as thereby the chances of in- 
fection are undoubtedly diminished. Taking into 
account the danger of this operation, and the com- 
paratively useful limbs which result from inte li- 
gent and careful conservative treatment, the con- 
clusion is clear that conservative treatment is best 
for the large majority of cases. In special cases, as 
in robust young men who are dependent on 
strong legs for their daily bread, the direct suture 
in competent hands is certainly advisable. 
To perform this operation, a longitudinal inci- 
sion is made over the center of the joint, which is 
opened, and the fragments of the patella are 
exposed; any blood-clot which is present in the 
joint or between the fragments is turned out, and 
the fragments themselves are cleared of any apo- 
neurotic and fibrous tissue which may be found 
lying between and over their broken surfaces. 
Each fragment is then bored obliquely with a drill, 
taking care not to reach its cartilaginous surface. 
Sutures of silver wire or of heavy catgut are then 
passed through the drilled holes, and the fragments 
having been drawn together, the ends of the wire 
are twisted, cut short, and then hammered down 
on the bone, where they may be allowed to remain 
permanently, without causing any irritation. 
Kocher's method of treating fractured patella 
Ununited Fracture of the 
Patella.-(Spencer and Gask.j KNEE-JOINT, INJURIES 
KNOT 
consists in passing a stout silver wire completely 
around the bone. A needle in a handle is passed 
through the ligament of the patella, through the 
tendon of the quadriceps, and out through the 
skin. It is then threaded and drawn back again; 
the broken fragments are drawn together, the wire 
twisted up over something, to protect the skin, 
and the openings dusted with iodoform. The 
limb is then placed upon a back splint, bandaged, 
and kept in this position for 3 weeks; at the end of 
this time the wire is cut, drawn out of the wound, 
and the sore points that are left dusted with iodo- 
form until the parts are healed. 
Knee-joint dislocations 
are very rare, though dis- 
placement of the semilunar 
cartilages, especially fol- 
lowing violent rotatory 
movements with flexed 
knee, are more frequent. 
Dislocation of the semi- 
lunar cartilages of the knee 
joint {subluxation, internal 
derangement of the knee) 
follows a twist of the 
partly flexed knee. The 
cartilages are torn from 
the tibia by rotation of the 
leg; the internal cartilage 
being the one usually 
affected. Any of its at- 
tachments or even the car- 
tilage itself may be rup- 
tured. 
The symptoms are 
severe pain in the knee and 
effusion into the joint 
which is locked in flexion; 
extension being impossible. This locking may not 
be present; such cases are sometimes diagnosed as 
sprains. In the latter tenderness is more general- 
ized and extension may relieve rather than increase 
the pain. The displaced cartilage may be felt, 
but more often palpation will reveal nothing but 
marked tenderness along the front of the upper 
surface of the tibia. Recurrences are frequent. 
The treatment is reduction'by increasing the 
flexion, rotating the leg, making firm pressure over 
the situation of the displaced cartilage, and extend- 
ing the leg. Often spontaneous reduction occurs 
before the surgeon is called. The synovitis should 
be treated and the knee immobilized for five or six 
weeks. In order to prevent recurrence an elastic 
knee-cap should be worn for several months. If 
relapses are frequent a brace may be applied, or 
the joint may be opened by a curved incision along 
the upper edge of the tibia, and the cartilages 
stitched to the periosteum with catgut, or excised 
if they are ruptured. 
Complete displacements may occur forward, 
backward, and laterally; they are combined with 
tearing of the lateral and crucial ligaments, result 
from the direct application of great force, and 
hence are usually complicated injuries. Such an 
injury is, of course, easily manifest. Reduction 
is by direct pressure and traction. Rotatory 
dislocation, from twisting, also occurs. In all 
dislocations of the knee the patient should wear 
an elastic knee-cap or a brace for several months 
after restitution of the joint. 
Dislocation of the patella may be outward, 
inward, and vertical (rotated about the long axis, 
this embracing also its complete reversal). The 
outward displacement is most frequent. These 
conditions are easily recognized, except the com- 
pletely reversed form, which is the greatest rarity. 
Complete extension of the leg with flexion of the 
hip will usually permit reduction. 
The fibula may be dislocated from the tibia at 
its upper (and lower) extremities. The head may 
be dislocated forward or backward. This injury 
may be associated with isolated fracture of the 
upper tibia. There is inability to bear weight 
with mobility of the head. After reduction a 
molded splint should be applied to fix the head. 
For further discussion of injuries of the knee- 
joint, see Joints (Injuries). 
KNOCK-KNEE.-See Genu Valgum. 
KNOT.-An interlacement of ends or parts of 
one or more cords or threads so that they cannot 
be readily separated. K., Clove-hitch, a knot 
Brace for Dislocated 
Semilunar Cartilage 
The mechanism permits 
flexion and extension, but 
prevents rotation.- 
(Wal sham.} 
Clove-hitch Knot. 
Combined Surgeon's and Reef Knot. 
Staffordshire or 
Tait's Knot. 
Granny Knot 
Surgeon's Knot. 
Reef Knot. 
consisting of two single, contiguous loops, the free 
ends toward each other. It is used for making 
extension in the reduction of dislocations. K., 
Double. Same as K., Friction. K., False. Same 
as K., Granny. K., Friction, one in which the ends 
are wound twice around each other before they 
are tied. K., Gerdy's Extension, resembles the 
clove-hitch; it is employed in making extension of KOCH'S POSTULATES 
KUMYSS 
the leg at the ankle. K., Granny, a tie of a cord 
in which in the second loop the end of one cord is 
over, and the other under, its fellow, so that the 
two loops do not lie in the same line. This 
knot may easily be converted into a slip-knot. 
K., Reef, a knot so formed that the ends come 
out alongside of the standing parts and the 
knot does not jam. It is also called square knot. 
K., Sailor's. Same as K., Reef. K., Square. 
Same as K., Reef. K., Staffordshire, a knot used 
in ligating the pedicle in ovariotomy. The liga- 
ture is passed through the pedicle, and withdrawn 
so as to leave a loop, which is passed over the tumor 
and one of the free ends is then drawn through 
the loop; both ends are then passed through the 
pedicle, tightened, and tied. It is also called 
Tait's knot. K., Stay, a term applied byBallance 
and Edmunds to a knot formed by two or more 
ligatures in the following way: On each ligature 
separately is made the first hitch of a reef knot, 
which is tightened so that the loop lies in contact 
with the vessel, without constricting it; then, 
taking the two ends on one side together in one 
hand, and the two ends on the other side in the 
other hand, the vessel is constricted sufficiently 
to occlude it, after which the reef knot is com- 
pleted. The simplest method of completing the 
knot is to treat the two ends in each hand as a sin- 
gle thread, and to tie them as if completing a sin- 
gle reef knot. K , Surgical, a double knot made 
by passing the thread twice through the same loop. 
K., Tait's. See K., Staffordshire. 
KOCH'S POSTULATES.-See Bacteriology. 
KOLA.-The nut or seed of Cola acuminata, 
used in parts of central Africa as a substitute 
for tea and coffee. It contains both caffein and 
theobromin, tannic acid and a glucosid substance 
named kolanin, which, in the presence of a fer- 
ment, splits up into free caffein and glucose. The 
Kola nut is said to be stimulant and aphrodis- 
iac. It improves the appetite and the digestion, 
and is useful in gastric catarrh and in the dyspep- 
sia of alcoholic subjects, as an adjunct to other 
treatment; also in asthma of both the nervous and 
cardiac forms. It is especially efficient in atonic 
diarrhea; and in gastrointestinal irritation with 
looseness of the bowels, a restricted diet and Kola- 
wine are frequently all that is needed. 
KOOMISS.-See Kumyss. 
KOUSSO.-See Cusso. 
KOPLIK'S SPOTS.-See Measles. 
KRAMERIA (Rhatany).-The dried root of 
Krameria triandra. It contains 20 to 45 percent 
of rhatania-tannic acid, also rhatantin, an alkaloid, 
and wax, gum, etc. Dose, 10 to 20 grains. 
It may be employed for the same purpose as 
tannic acid except as an antidote to antimony. 
It has been used as an injection for fissure of 
the anus, as a local application to spongy gums, 
as a tonic for debilitated subjects, in chronic 
diarrhea, also in passive hemorrhages and mucous 
discharges, as menorrhagia and leukorrhea. 
Preparations.-Extractum K., aqueous. Dose, 
5 to 10 grains. Fluidextractum K. Dose, 5 to 20 
minims. Tinctura K., 20 percent. Dose, 1/2 to 2 
drams. Syrupus K., has of the fluidextract 45 
parts, with syrup 55. Dose, 1/2 to 4 drams. 
Trochisci K., each troche contains nearly 1 grain 
of the extract, with tragacanth, sugar and orange- 
flower water. 
KYPHOSIS.-See Spine (Curvature). 
KUMYSS (Koomiss).-An effervescing fermented 
liquor originally prepared by the Tartars from 
mare's milk, but now imitated with cow's milk by 
adding sugar of milk, fermenting in open tanks, 
skimming off the casein and butter, then bottling 
during active fermentation. Its successful prepa- 
ration depends on its undergoing slow fermentation 
for 5 to 10 days in a cold room, at 40° F. If the 
temperature be higher than 50° the fermentation 
will be of the acetous variety, and will result in 
sour milk with heavy curd, feeble effervescence and 
repulsive taste. Kumyss has an acidulous and 
peculiar taste. It is a powerful diuretic, espe- 
cially in cold weather, and in warm weather it 
causes free perspiration. It is stimulant and tonic, 
increases the nutrition of the body and produces 
considerable somnolence. The stomach tolerates 
it well, even when it rejects all other food. It is 
easily assimilated and very nutritious. 
Kumyss is an invaluable article of diet in many 
wasting diseases, especially phthisis. It is of 
great benefit in dyspepsia, the diarrheas of children, 
convalescence from acute maladies, chronic affec- 
tions of the kidneys, and other cachexiae. In cases 
of feeble digestive power an ounce every hour is 
sufficient, but as its digestion and assimilation in- 
crease it may be given almost ad libitum, and 
when used with other food a half-pint may be 
taken after each meal. Each quart is estimated to 
contain four ounces of solid food, besides from 1 to 
3 percent of alcohol. See Kefir. LABARRAQUE'S SOLUTION 
LABOR 
L 
LABARRAQUE'S SOLUTION.-Solution of 
chlorinated soda; an aqueous solution of several 
chlorin compounds of sodium, containing at least 
2.4 percent by weight of available chlorin pre- 
pared by adding together aqueous solutions of 
monohydrated sodium carbonate 65, and chlorin- 
ated lime 90, then adding water to 1000. Dose, 
10 to 30 minims (average, 15 minims) in 20 parts 
of water. See Disinfection. 
LABIA, DISEASES.-There is a type of inflam- 
mation of the labia that resembles erysipelas in its 
extensive swelling and redness, but differs from 
it in the fact that it does not spread. It sub- 
sides in a few days, but if severe, it may produce 
sloughing. It is seen in typhus and small-pox, 
and after delivery. A wound may be found, or 
no history of any violence is to be elicited, without 
pregnancy or previous illness. The affection is 
usually bilateral. Treatment requires separation 
and support of the labia, and the application of 
an evaporating lotion like the following: 
conditions, the first when the parts are very sore. 
Silver nitrate, 20 grains to 1 ounce of water, may be 
applied once or twice a week. 
Warts on the labia, when nonsyphilitic, are 
acuminate, and not flat and overhanging. They 
are associated with uncleanliness and unchastity, 
but are not proof of the latter. A powder of 
calomel and zinc oxid may be used; they may be 
cut off if large, the hemorrhage being controlled 
by pressure, styptics, or the Paquelin cautery. 
Syphilitic warts, mucous tubercles, or condy- 
lomata are moist, broad, overhanging, white 
patches. Locally, black wash should be applied, 
and mercury given by the mouth. 
Epithelioma of the labia occurs as a warty growth, 
accompanied by ulceration, which shows no ten- 
dency to healing. 
The treatment of epithelioma is removal of the 
growth-best by the knife or Paquelin cautery- 
together with a good margin of healthy tissue. 
The inguinal glands on the corresponding side 
should be removed also if the growth is at all 
advanced. 
Innocent growths, as lipomata, are met with in 
the labia; and elephantiasis of the labia is occa- 
sionally encountered. These growths are to be 
treated by removal, if their bulk causes incon- 
venience. The labia may also be the seat of lupus 
and swelling or of hematoma. Boils sometimes 
are found here, and are distressing because of pain 
and the suspicion they suggest. Hydrocele 
of the labia must be carefully differentiated from 
hernia, and probably the safest practice is to 
cut down on the tumor, open it, and remove the 
sac. See Vulva. 
LABOR.-That natural process by which the 
fetus and its appendages are expelled from the 
uterus and vagina at the normal expiration of 
pregnancy. This should be about 280 days after 
appearance of the last menstruation. 
Causes.-Just why labor should occur at this 
particular time is unknown. It has been thought 
to be due to: (1) Periodicity, the muscular action 
of the uterus being particularly strong at the 
tenth period; (2) overdistention of the uterus, which 
is followed by retraction of the uterine muscle 
and expulsion of the fetus; (3) maturity of the 
ovum, the decidual cells undergoing fatty degenera- 
tion toward the end of pregnancy, thus causing a 
"loosening" of the ovum; (4) nervous impulse, 
reflected from the central nervous system through 
the sympathetic to the uterus; (5) when the 
uterus is incapable of further distention the 
fetus becomes practically a foreign body, and as 
such is expelled. 
Signs. 1. Subsidence of the Uterus.-This 
occurs about 4 weeks before term in primiparae, 
2 weeks before term in multiparse. It is due to 
retraction of the abdominal muscles, which forces 
I). Solution of lead acetate, 
Rectified spirit of wine, 
Water, O j. 
each, 3 ss 
If a tendency to gangrene is seen, the actual 
cautery is needed to separate the slough, followed 
by cleansing by frequent antiseptic lotions. 
Erysipelas may attack the labia, as any other 
part of the body. 
Herpes of the labia runs its usual course, re- 
quiring drying and sedative applications, such 
as bismuth, lead ointment, or an ointment con- 
taining bismuth, 30 grains; morphin, 10 grains; 
and vaselin, 1 ounce. 
Abscess of the labia is usually unilateral, gener- 
ally in Bartholin's gland, and is due to gonorrhea 
or traumatism. It forms a tender, fluctuating, 
and nonreducible swelling which, if left alone, 
will burst and refill, and thus continue indefinitely. 
The gland must be dissected out to obtain effectual 
cure. See Bartholin's Glands. 
Eczema of the labia is often found in elderly, 
plethoric, and gouty women and in the subjects 
of diabetes. Antacid remedies and purgatives 
are given, combined with rest, the avoidance of 
alcohol, and a restricted diet. 
1$. Magnesium sulphate, 5 j 
Magnesium carbonate, gr. x 
Aromatic spirit of ammonia, rq xx 
Water, 3 j. 
Give twice daily. 
For local application, lead ointment, zinc 
ointment, and an ointment of the nitrate of mer- 
cury and zinc ointment in equal parts may be 
used, the last being used in chronic and indolent LABOR 
LABOR 
the presenting part and lower uterine segment into 
the pelvic cavity. The size of the abdomen is 
decreased, the pressure-symptoms above, such as 
irritability of the stomach and difficult breathing, 
are relieved; and the pressure-symptoms below, 
as edema and excessive vaginal secretion, are 
increased. Should subsidence of the uterus not 
occur, it usually indicates a malposition of the 
child or some obstruction, as a contracted pelvis 
or oversized head. 
2. Pains.-These are felt over the sacrum and 
lower part of the abdomen. They are intermittent 
in character, occurring at first, about every 15 
minutes, and lasting about 1/2 to 1 minute. They 
should not be confounded with pains due to in- 
testinal colic or to rheumatism of the uterine 
muscle. 
3. Show.-This is a small plug of blood-tinged 
mucus which has occluded the cervical canal during 
pregnancy, and which is now expelled with the 
first few pains. 
4. Dilatation of the Os.-This is by far the most 
important sign, and when accompanied by 
effacement of the cervical canal, is a positive 
indication of labor. 
Stages.-Normal labor may be divided into 
3 stages: 
1. The Stage of Dilatation and Effacement.- 
This begins with the first pain and lasts until 
full dilatation of the os is accomplished. The 
average time required for the completion of the 
first stage is, in primiparse, 10 to 12 hours; in 
multiparae, 6 to 8 hours. 
2. The Stage of Expulsion.-This begins with 
full dilatation of the os, and lasts until the child is 
expelled from the vagina. Its average duration 
is, in primiparse, 2 to 4 hours; in multiparse, 1 to 2 
hours. 
3. The Placental Stage.-This covers the period 
which elapses between the birth of the child and 
the expulsion of the placenta and membranes. Its 
average duration is 15 minutes. 
Management.-A call to an obstetric case should 
be answered immediately. The strict observance 
of this rule may prevent many complications, 
such as malpresentations, lacerations of the peri- 
neum, postpartum hemorrhage, and asphyxia of 
the new-born. 
Certain articles are indispensable to the proper 
management of an obstetric case. The patient 
should provide the following: A half-pound can 
of ether, 2 ounces of brandy, 4 ounces of vinegar, 
4 ounces of tincture of green soap, 1 dozen tablets 
of mercuric chlorid, a large new sponge, a skein of 
bobbin, a fountain syringe, a bed-pan, a new soft- 
rubber catheter, 4 ounces of absorbent cotton, a 
bottle of carbolized vaselin, 2 yards of unbleached 
muslin, 1 pound of salicylated cotton, 5 yards of 
carbolized gauze, 8 yards of nursery cloth, and 2 
dozen clean towels. 
The physician's obstetric bag should contain 2 
pairs of forceps, preferably the Simpson and the 
Tarnier axis-traction; a Sims speculum; perineal 
needles and needle-holder; half a dozen hemostats; 
a pair of blunt-pointed scissors; a set of Barnes' 
bags; a hypodermic syringe; iodoform gauze; 
fluidextract of ergot; tablets of nitroglycerin; and 
a 2 percent solution of silver nitrate. 
The lying-in room should be large, sunny, and 
well ventilated, preferably by an open fireplace. 
It should not contain a stationary wash-stand, 
nor should it have any connection with a sewer, 
bath-room, or water-closet. If it is heated by a 
hot-air furnace, the intake for the air and the 
sanitary condition of the cellar may need investi- 
gation. No decomposing food, unemptied bed- 
pan or commode should be left in the room for any 
length of time. 
The water used for douches or for washing off 
the vulva or perineum should be sterilized by boil- 
ing it for at least one-half hour. 
The patient should receive a full bath before 
labor (special attention being given to the genital 
region), and be supplied with clean clothes. The 
mattress on which she lies should be clean and not 
soiled with discharges of previous labors or other 
putrescible material; it should be protected by a 
perfectly clean rubber cloth. The pads on which 
the buttocks rest during and after labor should be 
of nursery cloth, previously boiled and dried. 
The material used to wipe off the genital orifice, 
mouth of the urethra, and perineum should be 
absorbent cotton, soaked in mercuric chlorid solu- 
tion (1:1000) for one-half hour. After labor an 
antiseptic vulvar pad, composed of salicylated 
cotton and carbolized gauze, should be worn dur- 
ing the continuance of the lochial discharge. 
These pads should be changed and the vulva 
cleansed 4 to 6 times in the 24 hours. If there is 
any pathologic discharge, the vagina should be 
thoroughly cleansed by scrubbing with tincture of 
green soap, hot water, and pledgets of cotton, 
followed by a mercuric chlorid douche (1:2000); 
this followed by a douche of sterile water. 
The physician should not carry infectious germs 
upon his person or clothing. He should not 
attend an obstetric case after seeing a contagious 
disease without first taking a full bath and chang- 
ing his clothing. The preparation of his hands 
should consist of 10 minutes' scrubbing with tinc- 
ture of green soap, hot water, and a stiff nail-brush 
followed by scrubbing in alcohol, and immersion 
in mercuric chlorid solution (1:1000) for 2 minutes. 
The instruments used about the patient should 
first be boiled for 10 minutes. If boiling injures 
them, they should be immersed in mercuric chlorid 
solution (1:1000) for one-half hour. 
Examination of the patient must be made to 
determine the position and presentation of the 
child, its approximate size, the condition of the 
perineum, the dilatability of the vagina, the size 
of the pelvis, the amount of dilatation of the cervix, 
and the effectiveness of the pains. To ascertain 
the above facts an abdominal examination should 
first be made, the patient lying upon her back, 
with knees drawn up and shoulders slightly raised; 
followed by a vaginal examination, the patient 
lying in the Sims position. The vaginal examina- 
tions should be made as infrequently as possible, 
and always visually, so that the finger may not be 
contaminated by groping over the perineum or 
vulva before entering the vagina. By observing LABOR 
LABOR, PREMATURE 
these two precautions the dangers of sepsis are 
greatly reduced. 
During the first stage of labor the patient should 
be allowed to occupy her time very much as she 
pleases. The lower bowel should be thoroughly 
emptied by an enema of a pint of warm soapsuds 
and a dram of turpentine. The vaginal examina- 
tions should be made only when necessary and 
when the os is dilated to the size of a silver dollar, 
she should be placed in bed, lying upon that side 
toward which the fetal back looks. If the patient 
is nervous, or if she complains very much of the 
severity of the pains, she may be given chloral 
hydrate, in 15 grain doses, every 20 or 30 minutes, 
until she has taken 45 grains. A cup of beef-tea 
or a glass of sherry or milk will oftentimes act 
beneficially. 
During the second stage of labor the examina- 
tions should be made only when necessary. 
If, in a multipara, the membranes have not rup- 
tured, they should be perforated with the finger 
or with some aseptic instrument. Care should be 
exercised that the child's scalp or the lower uter- 
ine segment may not be injured. 
If the pains are very severe and if the patient 
complains excessively, chloroform or ether may be 
given. The latter is probably the safer. It should 
be given only during the second stage, and never 
in sufficient quantity to produce complete anesthe- 
sia. See Anesthesia; Twilight Sleep. 
During this stage the expulsive force of the ab- 
dominal muscles may be much increased by the 
use of a " puller." As the head advances toward the 
vulvar outlet, precaution must be taken to prevent 
laceration of the perineum. This is best avoided 
by making firm backward and upward pressure 
against the occiput during pains; by restrain- 
ing voluntary expulsive efforts during pains; 
and by securing expulsion of the head between 
pains. 
When the head is born, support it with the hand, 
wash the eyes carefully with warm sterile water, 
and if the cord is coiled about the neck, loosen it or 
slip it over the head. By this time the next pain, 
which secures delivery of the shoulders, will occur. 
Should this be delayed, stimulate the uterus by 
friction through the abdominal wall; or grasp the 
sides of the child's face with the two hands, make 
downward and forward traction until the anterior 
shoulder appears under the symphysis, then upward 
and forward traction, until the posterior shoulder 
appears, finally downward and forward traction, 
the anterior shoulder and remainder of the body 
being extracted in rapid succession. As the child 
is born one hand should grasp the fundus to secure 
and maintain firm contraction. The child should 
be placed by the mother's side, with its face turned 
away from the maternal discharges. As soon as 
the cord stops pulsating it should be ligated and 
cut. 
During the third stage of labor the patient should 
be carefully guarded against hemorrhage. A dram 
of the fluidextract of ergot should be administered 
to aid firm contraction; and irritation of the uterus, 
by friction through the abdominal wall, should be 
persisted in for 10 or 15 minutes. If, at the ex- 
piration of this time, the placenta has not been 
voluntarily expelled, the fundus should be grasped 
firmly between the thumb and 4 fingers; as soon 
as the uterus is felt to harden the fundus is com- 
pressed tightly, and firm downward and backward 
pressure is made in the direction of the pelvic axis. 
Very slight traction is made on the cord with the 
other hand, to guide the placenta through the 
cervix and vagina. The placenta should be re- 
ceived in some sort of a receptacle as it emerges 
from the vulva, and should then be carefully in- 
spected ; if it and the membranes are intact, and if 
the womb is firm, an abdominal pad and binder 
should be applied, all blood and discharges cleaned 
away, and the patient fixed comfortably in bed. 
For immediate care of the infant see New-Born 
Infant. 
LABOR, COMPLICATIONS AND SEQUELS.- 
See Eclampsia, Perineum (Injuries), Postpar- 
tum Hemorrhage, Puerperal Fever, Uterus, 
Vagina, etc. 
LABOR, DIFFICULT.-See Dystocia, Fetus 
(Positions and Presentations), Pelvis (Contract- 
ed), etc. 
LABOR, PREMATURE.-Expulsion of the fetus 
after it has become viable-after the sixth month 
of gestation. 
The causes and clinical phenomena of premature 
labor have been discussed under Abortion (q. v.}. 
The treatment is the same as labor at term. 
Induction of Premature Labor.-This becomes 
necessary at times for the preservation of the 
mother's life. Not infrequently, too, it offers to 
the child its best or only chance for safe delivery. 
Indications for the Induction of Premature 
Labor.-Besides the indications which were 
mentioned for the induction of abortion, we have 
the following: (1) Certain degrees of contracted 
pelvis (8 to 9.5 cm.); (2) placenta praevia; (3) grave 
systemic disease, as phthisis and advanced heart- 
disease; (4) habitual death of fetus just before 
term. 
Method of Inducing Premature Labor.-The 
most satisfactory method is by catheterization of 
the uterus. The steps of this method are as fol- 
lows: (1) Disinfect the cervical canal, vagina, 
vulva, pubes, and inner part of thighs by scrubbing 
thoroughly with tincture of green soap and pled- 
gets of cotton, followed by a vaginal douche of 
mercuric chlorid (1: 4000); (2) two fingers of the 
left hand, previously sterilized and well lubricated 
with 5 percent carbolized oil, should now be intro- 
duced into the vagina, the middle finger pressed 
against the external os, which will gradually dilate 
until the tip of the finger is at or beyond the inter- 
nal os; (3) an elastic silk bougie (No. 17 French), 
previously sterilized by soaking in cold mercuric 
chlorid solution (1: 1000) for one hour, is now 
passed along the groove between the middle and 
index-fingers until it enters the uterine cavity and 
extends from 7 to 9 inches between the decidua 
vera and decidua reflexa; (4) finally, the bougie is 
kept in position by a vaginal tampon of iodoform 
gauze. The patient then lies quietly in bed, labor 
beginning after a variable period, the average being 
12 hours. If, at the end of 12 hours, there are no LABOR, TWIN 
LACRIMAL DISEASE 
signs of beginning labor, a second and larger bougie 
may be inserted by the side of the first. If this 
fails, after the lapse of another 12 hours the cervix, 
which has become very much softened, may be 
easily dilated by means of Barnes' bags. 
If there is any necessity for immediate delivery, 
the patient should be anesthetized, the cervix 
dilated with fingers or dilators, the membranes 
ruptured, and podalic version performed. 
LABOR, TWIN.-See Pregnancy (Multiple). 
LACQUER POISONING.-Workers in lacquer, 
the base of which is the balsam of rhus vernicifera, 
are subject to a disease which resembles ivy poison- 
ing, though the symptoms are more intense. It is 
met with especially in China and Japan. There 
is severe pruritus with edema and papules of the 
face and extremities and probable involvement of 
mucous membranes and conjunctivae. 
Treatment.-Soothing lotions such as lime water 
and sodium thiosulphate solution (1 to 8) or solu- 
tion of aluminum acetate are indicated. 
LACRIMAL DISEASE. 
immediately endeavor to correct any malposition, 
as the sequences of epiphora are very serious, 
eventually leading to ectropion. In cutting 
operations on the lids, or in the application of 
caustics, we must always be careful that the puncta 
are not involved, as eversion, with its annoying 
sequels, will result if this precaution is not 
taken. 
Although it is always well to preserve the puncta, 
which have a physiologic function of importance in 
keeping solid, irritating bodies from the nasal 
duct and lacrimal sac, it is often necessary, for 
immediate drainage, to slit the canaliculus in- 
volved. This simple operation is performed as 
follows: The lower lid is drawn downward and 
outward, and slightly everted by the thumb of 
one hand, while the probe point of a canaliculus 
knife is introduced vertically with the other hand. 
When the knife is well inserted into the canal, 
its point is turned inward and slightly backward, 
reaching the inner wall of the lacrimal sac. Dur- 
ing this maneuver the edge of the knife is turned 
toward the conjunctiva, and the whole length of 
the canaliculus is divided, close to the mucocu- 
taneous'junction by bringing the knife up boldly 
from the horizontal to the vertical position. In 
dividing the upper canaliculus the upper lid is 
made tense, and the knife is introduced into the 
upper punctum and passed into the sac in a direc- 
tion downward and inward. If the canaliculus 
is very small, a fine-pointed conic probe should 
first be used to dilate it. There are various 
modifications of the operation-with a grooved 
director, fine scissors, etc. The wound should be 
examined at short intervals, and kept open with a 
probe. 
Affections of the Canaliculus.-Obstruction of 
the canaliculus is often due to a foreign body, 
such as an eyelash, which not only occludes the 
canal, but scratches the cornea. The obstruction 
may be due to a stone in the canaliculus, called a 
dacryolith. Polypi of the canaliculi may grow 
so luxuriantly as to protrude from the puncta. 
The treatment in these cases is to remove the 
foreign body if it protrudes from the punctum; 
or, if the obstruction is due to a stone or polypus 
or there is absolute stenosis or obliteration of the 
canaliculus, it should promptly be slit to its full 
extent. 
Affections of the Lacrimal Sac.-The lacrimal 
sac is lined with mucous membrane, which is 
subject to inflammation and catarrh like any 
other mucous membrane. Any condition which 
obstructs the free passage of the tears predisposes 
to disease of the sac, and particularly if the ob- 
struction is in the nasal duct. The sac also be- 
comes diseased by extension of any inflammatory 
process from the nose. Inflammation of the sac 
leads to blennorrhea, and this, in its turn, leads to 
dacryocystitis, or abscess of the lacrimal sac. 
The contents of a constantly suppurating tear- 
sac are very infectious, and although the patient 
may go on for many years with epiphora, con- 
junctivitis, and crusting of the lids in the morning, 
yet the infection may be so severe as to set up an 
inflammation which will eventually destroy the 
Diseases of the Lacrimal Gland. 
Abscess and inflammation of the lacrimal gland 
are very rare. The diagnosis depends on the 
presence of swelling or the signs of abscess in the 
region of the gland. An abscess should be incised, 
and any inflammation of the gland treated with a 
mercurial ointment or potassium iodid. 
New growths are mostly adenomata. A chloroma 
is a malignant greenish tumor which sometimes 
attacks the lacrimal gland. Sarcoma and carci- 
noma are also occasionally found in this location. 
However, disease of the lacrimal gland is so rare 
an affection that many men of vast experience 
have never seen a case. The treatment of a tumor 
is prompt excision. 
Dacryops is a condition in which a lacrimal duct 
becomes occluded and the lumen full of secretion, 
forming a bluish tumor on the outer upper fold of 
the conjunctival sac. It should be opened with 
a fine needle. 
Fistula of the lacrimal gland is usually the re- 
sult of injury or operation. The fistula should be 
connected with the conjunctival sac, after which 
the dermal opening soon heals. 
Diseases of the Lacrimal Passages. 
The all-important sign of diseases of the lacrimal 
passages is the overflow of tears, or epiphora. 
The first purpose in treatment of such cases is to 
clear the passages so that the tears will run into 
the nose. However, we must remember that in 
oversecretion the tears will run over the cheeks. 
Thus, on a windy day or in emotional weeping 
there is not only extra secretion into the nose, 
causing sniveling, thus proving that the nasal 
duct is patulous, but, in addition, epiphora. 
Oversecretion of tears may be due to conjuctivitis, 
keratitis, an especially irritable trigeminus nerve, 
uncorrected ametropia, and a number of other 
causes. 
Eversion of the puncta, or even of the lower 
punctum alone, will cause epiphora. We should LACRIMAL DISEASE 
LACTIC ACID 
eye. The slightest abrasion of the cornea may 
become infected and a dangerous ulcer result. 
Dacryocystitis.-The initial symptoms are con- 
junctivitis, local pain, and redness of the skin. 
The distended sac soon appears as a tumor in- 
volving the tissues near the inner canthus of the 
eye. If left to itself, this tumor may ulcerate and 
the pus burrow through the skin, establishing 
what is known as a lacrimal fistula, which may re- 
main a lifetime, and become in itself a safeguard 
against a new attack. Often the distended sac 
loses its elasticity and becomes a permanent tumor, 
called hydrops sacci lachrymalis. 
The diagnosis of simple catarrh, blennorrhea, 
or hydrops is easily made by emptying the sac with 
pressure of the finger: in catarrh, a watery secretion 
appears at the punctum; in blennorrhea there is 
more or less pus; in hydrops, the sac may empty 
into the nose and no secretion appear. Dacryocys- 
titis and fistula need only be seen to be recognized. 
Treatment.-Any nasal affection should be 
corrected, and a free passage for tears into the nose 
established. The latter is generally effected by 
the passage of sounds. Bowman's sounds or 
probes are usually employed. The canaliculus 
should be slit, and the following day the passage 
of probes commenced. It is optional which canal- 
iculus is used, but the upper is shorter and easier to 
sound. 
To pass a lacrimal sound or probe, the point of 
the sound must be passed along the floor of the 
slit canaliculus to the nose, until it is felt to strike 
against bony resistance; the sound is then rotated 
until it points downward; keeping close to the inner 
wall of the sac, the sound is then firmly pushed 
along. Under ordinary circumstances, if the 
probe is in the right position, it will pass along the 
nasal duct with a moderate pressure; undue 
resistance to a small probe indicates stricture of 
the duct or a false passage; in either case the 
pressure should be used cautiously. If the sound 
has passed easily, it should be left in position 
several minutes; in fact, it may remain one-half 
hour often to advantage. If the passage has been 
tight, the sound should be immediately withdrawn. 
The sounding of the passage should be repeated 
every 3 or 5 days, and the size of the sounds 
progressively increased. In some cases it is well 
for the patient to wear a leaden stilet constantly 
for several days. Theobald and others advocate 
the use of very large lacrimal sounds. A special 
probe-pointed knife has been devised for slitting 
strictures of the nasal duct. In treatment of the 
lacrimal passages we should resort to frequent 
syringing, various astringent and antiseptic prep- 
arations being used. Weak solutions of silver 
nitrate are of benefit in blennorrhea. 
Recently there has been a reaction against pro- 
miscuous probing in lacrimal disease. The results 
are generally unsatisfactory and the case is often 
protracted. As a substitute there has lately 
been advised copious syringing with a fountain 
syringe attached to a hollow No. 4 Bowman's 
probe. The canaliculus need only be split half- 
way, and in some cases not at all. Boric acid and 
weak antiseptic solutions are used in the irrigations. 
A simpler treatment of lacrimal obstruction, 
which dispenses with mutilation of the puncta 
and canaliculus and probing, consists in the fol- 
lowing manipulations: 
First empty the sac and canaliculi by dexterous 
pressure, and cleanse the eye and palpebral pockets 
of the unhealthy material. Then cant the patient's 
head back and to one side, or have him lie so that 
a teaspoonful of liquid will be held in the depression 
formed by the nose, orbital border, and superior 
maxilla. Fill this space with a weakly antiseptic 
solution. A good solution is composed, to the 
ounce of distilled water, of boric acid, 10 grains; 
common salt, 3 grains; chlorid of zinc, 1 grain- 
all deeply tinted with pyoktanin-blue, and doubly 
filtered after long standing. With the little 
finger again slowly empty the sac and canaliculi 
by pressure, and then, as slowly lessening the 
pressure, allow these spaces to refill, by suction 
and capillary attraction, with the solution under 
which the puncta are submerged. Again, in half 
a minute, empty the canaliculi and sac by pressure, 
but this time beginning the pressure from the 
canthus toward the nose and downward, so as to 
force the antiseptic solution downward into the 
duct. These alternate emptyings and refillings 
of the sac may be repeated several times and as 
often as desirable to meet the indications of the 
case. It will usually be found that the sac will 
soon become healthy, and that pressure upon 
it will not cause regurgitation of morbid material 
through the puncta. 
A certain number of cases, however, will not 
yield to this treatment. There is too great stenosis 
or spasmodic contraction of the muscular sphincter 
of the punctum, etc., so that the cleansing solution 
cannot be forced into the sac and duct. In such 
cases it is well to insert one sharp point of the iris- 
scissors into the punctum, and snip it open about 
1 /8 of an inch, perpendicularly downward toward 
the conjunctival fold. This gives a larger opening 
for the indrawal of the solution. 
Obliteration of the lacrimal sac is a questionable 
procedure. The treatment of acute dacryocystitis 
consists in voiding the pus, either through the 
canaliculus or by an incision through the skin. 
The fistula is treated like other fistulous passages, 
and will generally heal if the obstruction to the 
passage of tears is removed. Repeated irrigation, 
syringing, and probing are the important after- 
treatments of all these affections. 
LACTATION.-See Breast, Infant Feeding, 
Milk (Mother's), New-born Infant. 
LACTIC ACID.-A liquid composed of 75 per- 
cent by weight of absolute lactic acid, and 25 
percent of water; nearly colorless, syrupy, odor- 
less, of acid taste and reaction, freely miscible 
with water, alcohol and ether, but nearly insoluble 
in chloroform. It is produced by the lactic fer- 
mentation of sugar of milk or grape sugar, and is 
difficult to obtain pure. It enters into syrupus 
calcii lactophosphatis. Dose, 20 minims to 1 dram 
(average, 30 minims), well diluted. 
It aids digestion and promotes the appetite, but 
in large doses causes flatulence and much epigas- 
tric pain. It dissolves false membranes and also LACTOPHENIN 
calcium phosphate. Hypnotic properties have 
been ascribed to it. 
Lactic acid is used with benefit in diabetes, 
atonic dyspepia, oxaluria, and in the lithic and 
phosphatic diatheses, when due to imperfect 
digestion and assimilation. As a solvent of false 
membrane in diphtheria it is unquestionably of 
great service, but painful. In chronic cystitis it 
arrests the ammoniacal decomposition in the 
urine. As the acid found in the shops is generally 
of poor quality, disappointment in its use may be 
expected. It has been used in tuberculous ulcer- 
ation of the tongue: lactic acid, 80 parts; water, 
20 parts, brushed daily over the ulcerated surface 
with a camel's-hair brush. 
LACTOPHENIN.-A phenetidin derivative con- 
taining a lactic acid radicle instead of the acetic 
acid one of acetphenetidin (phenacetin). Its action 
is analgesic, antipyretic, and hypnotic; and it has 
been recommended as a substitute for phenacetin 
because of its greater solubility. Dose, 8 grains 
to begin with (for adults); maximum daily dose, 
45 to 75 grains in wafers. 
LACTUCARIUM (Lettuce).-The concrete milk- 
juice of lactuca virosa. It is partly soluble 
in alcohol and in ether, and yields a turbid mix- 
ture when triturated with water. Lactucarium 
is a mixture of several substances, the most impor- 
tant beng lactocin, which is thought to be the 
active principle. It occurs in white scales, is solu- 
ble in water, and is used as a sedative and hypnotic 
in doses of 1 to 5 grains. Lactucarium also con- 
tains three bitter principles, lactucin, lactopicrin 
and laducic acid; also laducerin, an inert, waxy 
substance, constituting nearly one-half of the drug. 
A minute quantity of a mydriatic alkaloid, believed 
to be hyoscyamin, has been found in the plant, but 
not in commercial lactucarium. Dose, 10 to 20 
grains. 
Lactucarium is feebly hypnotic, somewhat seda- 
tive and diuretic. It is supposed to act similarly 
to opium, but very feebly and without depressing 
after-symptoms. Its preparations are very uncer- 
tain in activity, and are chiefly used as placebos, 
to allay cough and quiet nervous irritability. The 
syrup is a good vehicle for expectorants and anti- 
spasmodics. 
Tinctura L., 50 percent. Dose, 10 minims to 2 
drams according to the activity of the drug. Syr- 
upus L., has of the tincture 10 percent. Dose, 1 
to 8 drams. 
LAGOPHTHALMOS.-A condition in which the 
eyeball is so extruded that the lids cannot be com- 
pletely closed. The exposure of the eye following 
this condition is accompanied by the greatest dan- 
ger to the cornea. Lagophthalmos may be due to 
staphyloma of the cornea, ocular or orbital tumor, 
exophthalmic goiter, or paralysis of the orbicu- 
laris muscle. 
LA GRIPPE.-See Influenza. 
LAMBERT'S TREATMENT FOR NARCOTIC 
ADDICTION.-This treatment, originated by Mr. 
C. B. Towns of New York, has been described by 
Dr. Alexander Lambert, of the same city, and is best 
known under his name. Previous to its publica- 
tion, the usual treatment had been to deprive the 
patient slowly or quickly of his narcotic on the 
theory that deprivation from a narcotic would 
soon wear off the desire for it. But deprivation 
instead of obliterating the craving, intensified it. 
A patient deprived of his morphin or alcohol 
counts the days or hours until he can return to 
his narcotic, and this longing for it and looking 
forward to it has been known to last for weeks and 
months. After this treatment has been correctly 
given the desire for the narcotic is gone, and 
although the patient may feel weak and relaxed, 
he does not feel the craving. This treatment 
will take a morphinist from his drug without undue 
suffering, and will put him in a position in which he 
may be built up and given a chance to be free 
from his drug. It will do the same for the man 
who takes cocain. It has also been successfully 
used for tobacco, and the habits of the coal-tar 
hypnotics such as veronal and trional. This 
treatment will put an alcoholic on his feet, make 
him absolutely sober, and with all desire for his 
alcohol gone. It will give the man who wishes to 
be helped a chance to be free from his habit. 
After a man has been freed from the desire for his 
drug-the after treatment is of the greatest impor- 
tance. The patient should be made to realize 
that he is mentally just unpoised, and his nervous 
system cannot as a rule stand the strain of worry 
and work. He must be built up physically into 
as perfect a condition as circumstances will per- 
mit, and this will take usually three weeks or a 
month, or longer. If this is done, the physical 
condition will not tempt the mind back into the 
seductive taking of little nibbles at his drug, which 
to his mind don't count, but which in reality are 
the beginning again of all the old habit. It is 
useless to compromise; the man who has taken 
alcohol to excess, or morphin or cocain to excess, 
cannot again touch these things without great dan- 
ger of relapse to all their excesses. The first 
drink will start up all the old desires with the 
same inevitable results. To the man who has 
indulged excessively, his nervous system and 
alcohol are chemically incompatible. The alcohol 
forms a poisonous combination with the brain 
cells which perverts the normal reaction of these 
cells. There is no question that it poisons the 
higher functions of the brain and perverts 
them. It is useless for him to ever hope to 
drink again in moderation. Many alcoholics 
have the faint hope back in their minds, 
against everything that is told them, everything 
they have experienced, and everything which 
their own judgment dictates, that some day they 
may be able to drink without going to excess. 
This summum bonum of their desires is always 
being sought for and never attained, and the self 
deception goes on; they are always trying to see 
if the first few drinks cannot be taken with impu- 
nity. This is one of the reasons why so many men 
revert. It is useless to endeavor to help a man 
who does not want to be helped. It is useless to 
waste time giving a treatment to take away the 
craving for narcotics to an individual who has no 
intention of trying to stop. The Lambert treat- 
ment is distinctly contraindicated in those who are 
LAMBERT'S TREATMENT LAMBERT'S TREATMENT 
LAMBERT'S TREATMENT 
not willing to help to stay sober. It is also contra- 
indicated in pregnant women, as the very active 
cathartics may sometimes produce a miscarriage. 
The method of administering this treatment has 
been most recently described in the Journal of 
the American Medical Association of February 
18, 1911, and is as follows: 
The belladonna mixture of two parts 15 percent 
tincture of belladonna, and one part each of the 
fluidextracts of hyoscyamus and xanthoxylum, 
has proved itself an essential part of the treatment. 
When the 10 percent tincture of belladonna has 
been used, or when even a 12 percent tincture 
has been employed, the results obtained were not 
clear-cut, but left the patients with an indefinite 
nagging longing for their narcotic. It seems 
necessary to push this mixture to the physiologic 
tolerance of the belladonna. This tolerance, of 
course, varies with the individual, and some of 
the best results have been obtained with patients 
who could not tolerate as an hourly dose more 
than from 2 to 4 drops of this mixture, while others 
easily tolerated from 18 to 20. It would seem, 
judging from clinical results, that there are some 
properties in this mixture which are necessary to 
a successful carrying out of the treatment. The 
bottle containing this mixture must be kept well 
corked, and shaken before using. The method 
which Lambert pursues is as follows: 
A patient addicted to morphin is given five com- 
pound cathartic pills and 5 grains of blue mass, 
and, six hours later, if these have not acted, they are 
followed by a saline; after three or four abundant 
movements of the bowels from these cathartics, 
the patient is given, in three divided doses at half- 
hour intervals, two-thirds of the total daily 
twenty-four-hour dose of morphin or opium to 
which he has been accustomed. Observe care- 
fully after the second dose has been given, as the 
amount then equals four-ninths or nearly one-half 
the total twenty-four-hour dose. Some few 
patients cannot comfortably take more than this 
amount. At the same time with the morphin, 6 
drops of the belladonna mixture are given in cap- 
sules. This belladonna mixture in doses of 6 
drops (and by drops are not meant minims, but 
drops dropped from an ordinary medicine drop- 
per, which is about half a minim dose) is given 
every hour for six hours. At the end of six hours 
the dosage is increased 2 drops. The belladonna 
mixture is continued every hour of the day and 
every hour of the night continuously throughout 
the treatment, increasing 2 drops every six hours 
until 16 drops are taken, when it is continued at 
this dosage; it is diminished or discontinued at any 
time if the patient shows belladonna symptoms 
such as dilated pupils, dry throat or redness of the 
skin, or the peculiar and incisive and insistent 
voice, and insistence on one or two ideas. It is 
begun again at reduced dosage after the above 
symptoms have subsided. 
At the tenth hour after the initial dose of mor- 
phin is given, the patient is again given five com- 
pound cathartic pills, and 5 grains of blue mass. 
These should act in six or eight hours after they 
have been taken. If they do not act at this time 
some vigorous saline is given, and when they have 
acted thoroughly the second dose of morphin is 
given, which is usually about the eighteenth hour. 
This should be one-half the orginal dose; i. e., one- 
third of the original twenty-four-hour daily dose. 
The belladonna mixture is still continued, and 
ten hours after the second dose of morphin has 
been given, that is about the twenty-eighth-hour, 
five compound cathartic pills are again given and 
5 grains of blue mass, these again if necessary 
followed by a saline seven or eight hours later. At 
times when the C. C. pills are not acting well, or 
too slowly, five or six " B. B." pills are given from 
two to three hours after the C. C. pills. These 
"B. B." pills are the pilulae catharticae vegetabiles 
of the pharmacopeia with 1/10 grain of oleoresin of 
capsicum, 1/2 grain of ginger, and 1/25 minim of 
croton oil added to each pill. After these have 
thoroughly acted at about the thirty-sixth hour, 
the third dose of morphin is given, which is one- 
sixth of the original dose. This is usually the 
last dose of morphin that is necessary. Again, 
ten hours after this third dose of morphin, i. e., 
the forty-sixth hour, the five C. C. pills and 5 
grains of blue mass are again given, followed in 
seven or eight hours afterward by a saline, and one 
expects at this time to see the bilious green stool 
appear. When this appears, after the bowels 
have moved thoroughly, ten or twelve hours after 
the third dose of morphin, about the fifty-sixth 
hour, two ounces of castor oil are given to clear out 
thoroughly the intestinal tract. During this last 
period when the bowels are moving from the C. C. 
pills and before the oil is given, the patients have 
their most uncomfortable time. Their nervous- 
ness and discomfort can be controlled usually by 
codein, which can be given hypodermically in 5 
grain doses and repeated if necessary, or some 
form of the valerianates may help them. About 
the thirtieth hour these patients should be stimu- 
lated with strychnin or digitalis, or both. After 
they are off their drug, the tonics which do them 
the most good are those which contain some form 
of phosphorus and arsenic; and here a warning 
must be given as to the danger of these patients 
overeating, and thus bringing back all their with- 
drawal symptoms due to the disturbance of diges- 
tion. They have been in the habit of referring 
all uncomfortable feelings to those of the with- 
drawal symptoms of morphin, and digestive dis- 
turbances feign these withdrawal symptoms. 
Sometimes about the thirty-sixth hour the stools 
become clay-colored. Some form of prepared ox- 
gall is most effective to stimulate further biliary 
secretion given in small doses every hour for five 
or six doses. 
In treating an alcoholic, the belladonna mixture 
and the five C. C. pills and 5 grains of blue mass 
are given simultaneously at the first dose. The 
belladonna mixture is continued every hour of the 
day and every hour of the night the same as with 
the morphin patients, and twelve hours after the 
initial dose patients are again given from three to 
five C. C. pills, and at the twenty-fourth hour after 
the initial dose, they are again given the cathar- 
tics followed by salines if necessary, and again LAMBERT'S TREATMENT 
LARGIN 
at the thirty-sixth hour. After these cathartics, 
the bilious stools will appear, and by the forty- 
fourth or forty-fifth hour the castor oil is given. 
Sometimes it is necessary to carry on the treat- 
ment over another period, and the C. C. pills and 
blue mass are again given at the forty-eighth hour, 
which would bring the end of the treatment about 
the sixtieth hour. 
Elderly or very nervous patients who have been 
on a prolonged debauch are tapered off with 2 
ounces of whisky for four or five doses through 
the first twenty-four hours. If these patients are 
excessively nervous it is necessary also to see that 
they sleep, and the mixture of chloral hydrate, 
20 grains; morphin, 1/8 grain; tincture of hyoscy- 
amus 1/2 dram; ginger, 10 minims; and capsi- 
cum 5 minims; water 1/2 ounce; which was recom- 
mended before is the best hypnotic for them. 
These patients should also have cardiac stimulants 
such as strychnin and digitalis after the first 
twenty-four hours, sooner if they are weak. If 
the patient has an alcoholic gastritis and cannot 
retain medicine, it is wise to give him 5 grains of 
Tully's powder (pulvis morphinse compositus) 
with 5 grains of sodium bicarbonate about every 
two hours for two or three doses, as this seems to 
be the most effective method of allaying the 
vomiting of an alcoholic gastritis. 
The cocainist can be treated like the alcoholic, 
except that no cocain is given at any time, and 
strychnin or some such stimulant must be given 
from the beginning of the treatment. 
The lasting effects of this treatment are of 
course greatly influenced by the environment in 
which the patient must live after he has had the 
treatment. As was said before, if he be in as fine 
physical condition as is possible, he stands the 
best chance of being able to resist. Except in the 
elderly, and those in whom there is danger from 
cardiac degeneration physical exercise is the 
■very best after treatment. They should not be 
treated with a rest cure, but should be built up 
by physical exertion. As soon as they are in good 
physical trim they will do better if the responsibil- 
ity of some occupation is given them, rather than 
distrust and idleness. It is a very noticeable fea- 
ture in treating these patients, especially the alco- 
holics, that those who are addicted to a cigarette 
habit are much more prone to relapse than those 
who do not smoke at all, or even than those who 
smoke cigars or a pipe. It is the constant poison- 
ing by an incessant accumulation of small doses of 
tobacco poison, which finally amounts to a chronic 
tobacco poisoning. This wears on their nerves, 
and their nerves must be quieted by some narcotic 
and they turn to the one to which they are most 
accustomed and moving in the line of least resist- 
ance drop back into their old habits. If a man 
who drinks to excess can be treated at the same 
time for his cigarette habit, it increases the prob- 
ability of his remaining abstinent. This treat- 
ment must not be considered as a cure-all and a 
regenerator of the weak minded and congenitally 
unfit members of the human race, but it will give 
those who desire to break away from narcotic 
addiction a chance to do so, and a chance to go 
on in life successfully where they might other- 
wise fail. 
LAMINARIA (Sea-tangle).-A seaweed, Lamin- 
aria digitata, found upon the shores of Great Brit- 
ain. It has a stem from 6 to 15 feet in length, and 
about 1 inch to 11/2 inches in diameter at its 
largest part. The stem shrinks to a marked degree 
in drying. The dried pieces, when again moist- 
ened, quickly regain their natural size. This 
property makes laminaria valuable for the manu- 
facture of tents and bougies. The plant is one of 
the sources of iodin, which it contains in large pro- 
portion. W hen burned, it produces a superior, 
fine-grained charcoal. See Tent. 
LAMINECTOMY.-See Spine (Injuries). 
LANDRY'S PARALYSIS.-See Paralysis 
(Acute Ascending). 
LANOLIN (Adeps lanae hydrosus).-The puri- 
fied fat of the wool of sheep, mixed with not more 
than 30 percent of water. A yellowish-white, 
ointment-like mass of faint, peculiar odor, insolu- 
ble in water, but miscible with twice its weight 
thereof. It is a cholesterin fat, differing from 
other fatty substances chiefly in resisting saponifi- 
cation and the action of water, and having no ten- 
dency to become rancid. It readily passes 
through the integument, carrying with it any 
medicament with which it is charged. It is a 
neutral base, and not likely to decompose any sub- 
stance. It is peculiarly useful in chronic skin-dis- 
ease where there is infiltration. It is inferior to 
lard, vaselin, or cold cream when a simple protec- 
tive action alone is desired. 
LAPAROTOMY.-See Abdominal Section. 
LAPPA (Burdock).-The dried root of Arctium 
Lappa, and of other species of Arctium. It con- 
tains a bitter principle, traces of a volatile oil, also 
inulin, resin, tannin, mucilage, sugar, etc. Dose, 
20 to 45 grains. 
Lappa promotes all the secretions and is con- 
sidered aperient, diuretic and diaphoretic, with- 
out irritating qualities. In decoction it has been a 
popular domestic remedy for many morbid condi- 
tions, especially rheumatism, gout, pulmonary 
catarrhs, and chronic cutaneous affections. It 
has been used as an alterative in constitutional 
diseases, as syphilis and scrofula, also as an exter- 
nal application to swellings, hemorrhoids and 
chronic sores. 
Fluidextractum Lappae, made with diluted alco- 
hol. Dose, 20 to 45 minims. 
LARD (Adeps).-The prepared internal fat of 
the abdomen of the hog, ' purified by washing, 
melting and straining. It occurs as a soft, white, 
unctuous solid, of bland taste and neutral reaction, 
entirely soluble in ether, benzin, and bisulphid of 
carbon; composed of 38 percent of stearin and 
margarin, and 62 percent of olein. Lard forms 
50 percent of ceratum, and 80 percent of unguen- 
tum, and enters into the composition of several of 
the official cerates. 
Preparations.-Adeps benzoinatus, benzoinated 
lard, has 2 percent of benzoin in powder, incor- 
porated by stirring. Oleum adipis, lard oil, is a 
fixed oil expressed from lard at a low temperature. 
LARGIN.-A silver-albumin compound, which LARYNGEAL MUSCLES, PARALYSIS 
LARYNGISMUS STRIDULUS 
m the air-dried condition contains. 11 percent 
of silver. It forms a gray powder, which is solu- 
ble in 10 parts of water. 
Largin is a powerful bac- 
tericide and astringent, 
like silver nitrate, but is 
nonirritant, and is not pre- 
cipitated by sodium 
chlorid or albumin. It is 
chiefly used in gonorrhea 
in 1/4 to 1 1/2 percent 
solution. 
LARYNGEAL MUS- 
CLES, PARALYSIS. 
Etiology.-Central ner- 
vous lesions, as bulbar 
paralysis; peripheral ner- 
vous lesions, affecting the 
recurrent laryngeal nerve 
(such as aortic aneurysm, 
tumor of mediastinum, 
diphtheritic paralysis); 
local lesions of the vocal 
cords (such as ulceration 
due to syphilis, or tuber- 
culosis) ; and hysteria. 
The nerves involved are 
the superior laryngeal and 
the recurrent laryngeal 
(both branches of the 
pneumograstric nerve). 
The following oft-quoted 
table from Gowers shows 
the symptoms, laryngo- 
scopic picture, and lesions. 
Treatment, is that of 
the cause; electricity and 
strychnin have also been employed. 
LARYNGISMUS STRIDULUS.-A peculiar form 
of laryngo-respiratory spasm, occurring almost 
exclusively in rickety children. There is no lesion 
of the larynx, it being usually a pure neurosis. 
The characteristic feature of the attack is a sudden 
"holding of the breath" for a few seconds; the 
glottis is then burst open, the air rushing in with 
a stridulous sound. In a severe attack not only 
the glottis, but the epiglottis, is closed, and the 
respiratory muscles are in a state of spasm. The 
exciting cause is most commonly some emotional 
disturbance, while dentition, irritation of the 
larynx or pharynx, nasal adenoids, or constipation 
may act as exciting causes. 
The following table gives the chief points of 
diagnosis: 
Laryngismus 
(Spasm of the 
Glottis) . 
Spasmodic 
Laryngitis. 
Membranous 
Croup. 
Occurs in rickety 
children 18 months 
of age. 
No fever, no coryza 
and no laryngeal 
catarrh. 
Occurs at any per- 
iod of the 24 hours, 
and often many 
times. 
No cough; inspira- 
tions are stridu- 
lous. 
Contraction of the 
limbs or general 
convulsions not un- 
common. 
The attack lasts a 
few seconds and 
then recurs fre- 
quently. 
Occasionally fatal... 
Rarely occurs 
under 2 years of 
age; commonest 
2 to 7 years. 
Slight fever, most- 
ly coryza and 
laryngeal ca- 
tarrh. 
Attack occurs at 
night. 
Metallic cough, 
stridulous respi- 
rations, varia- 
ble dyspnea. 
Convulsions rare. 
Attack passes off 
in the course of 
an hour or two. 
Rarely fatal 
Occurs at all ages 
during child- 
hood. 
Variable amount of 
fever and perhaps 
some diphtheria of 
fauces. 
Mostly worse at 
night. 
Metallic cough, 
stridulous respira- 
tion, progressive 
dyspnea. 
Convulsions rare 
Becomes steadily 
worse, though 
variations occur 
in its progress. 
Very often fatal. 
Vocal Cobds (Diagram- 
matic Mirror Picture) . 
1. Normal position in 
breathing and phonation 
respectively. 2. Adduc- 
tor paralysis (left); 2'. bi- 
lateral adductor paralysis. 
Both in phonation. 3. 
Unilateral abductor (left) 
and 3'. Bilateral abductor 
paralysis both during 
breathing. 4. Left recur- 
rent paralysis phonation. 
4'. Same in respiration. 
4". Recurrent bilateral in 
both respiration and pho- 
nation. 5. Arytenoid par- 
a 1 y s i s phonation. 5', 
Thyroarytenoid paralysis, 
phonation. 5". Arytenoid 
and thyroarytenoid para- 
lysis.-{Greene.} 
Symptoms. 
Signs. 
Lesion. 
(a) No voice; no 
cough; stridor 
only on deep 
inspiration. 
Both cords mod- 
erately abducted 
and motionless. 
Total bilateral 
palsy. 
(6) Voice 1 o w - 
pitched and 
hoarse, no 
cough; stridor 
absent or slight 
on breathing. 
One cord moderate- 
ly abducted and 
motionless, the 
other moving free- 
ly and even be- 
yond the middle 
line in phonation. 
Total unilateral 
palsy. 
(c) Voice little 
changed; cough 
normal; inspir- 
ation difficult 
and long, with 
loud stridor. 
Both cords near to- 
gether, and during 
inspiration not 
separated, but 
even drawn nearer 
together. 
Total abd u c t o r 
palsy. 
(d) Symptoms in- 
conclusive; lit- 
tle affection of 
the voice or 
cough. 
One cord near the 
middle line, not 
moving during 
inspiration; the 
other normal. 
Unilateral abduc- 
tor palsy. 
(e) No voice; per- 
fect cough; no 
stridor or dysp- 
nea. 
Cord normal in po- 
sition and moving 
normally in res- 
piration, but not 
brought together 
on an attempt at 
phonation. 
Adductor palsy. 
Treatment.-During the spasmodic stage, while 
the breath is being held, attempts to excite the in- 
spiratory center reflexly must be made. Cold 
water may be dashed in the face, the back may be 
patted, or a vigorous shake be given. Fanning the 
face vigorously during an attack is also useful. 
Hooking back the epiglottis with the forefinger 
is usually followed by an inspiration. A catheter 
may be passed into the larynx, or intubation per- 
formed, while quick tracheotomy is indicated if 
other means are nbt speedily followed by relief. 
The most useful medicines to check attacks are 
chloral, bromids, and minute doses of morphin. 
Potassium (or sodium) bromid, with chloral, may 
be given to an infant of 6 months, and repeated 
every 6 hours. 
I|. Potassium bromid, 5 ij 
Chloral, gr. xxxij 
Peppermint water, 5 ij- 
Teaspoonful every half hour. 
The diet and surroundings are most important. 
Fresh air is imperative; and a steam tent and close, LARYNGITIS, ACUTE 
LARYNGITIS, CHRONIC 
hot room are the worst possible things. A change 
to the seaside works wonders, and medicines 
which assist and regulate the bowels, such as 
extract of malt, rhubard and soda, acids and 
pepsin, and cod-liver oil, when it can be digested, 
are indicated. 
LARYNGITIS, ACUTE.-Acute catarrhal laryn- 
gitis; mucous laryngitis. 
Acute inflammation of the mucus membrane 
lining the larynx. 
Etiology.-(1) Sudden changes in the atmos- 
phere; (2) exposure to the cold and wet; (3) 
immoderate use of voice; (4) inhalation of dust 
or chemicals; (5) traumatism; (6) certain diseases 
act as predisposing causes, such as tuberculosis, 
rheumatic diathesis. 
Pathology.-The mucous membrane is red and 
highly congested, the swollen capillaries being of 
larger volume, and traverse the surface of the 
membrane in all directions. Large quantities of 
mucus are secreted, and form a coating over the 
vocal bands. In some cases the serous material 
is retained within the cellular tissue, causing occlu- 
sion of the glottis (edema of the larynx). The 
latter condition is more common in tuberculosis 
or syphilis. 
Symptoms.-There are, commonly, hoarseness, 
cough, expectoration of a viscid secretion, dryness 
of throat, and pain on deglutition. In children 
the respiration is frequently embarrassed, and 
paroxysms of croup may occur. Physical ex- 
amination reveals a reddened condition of the 
mucous membrane lining the organ, and also 
affecting the vocal bands, which lose their char- 
acteristic shining appearance. 
Diagnosis is determined by the subjective and 
objective symptoms. 
Prognosis is favorable. 
General Treatment.-Calomel should be given in 
fractional doses (1/4 of a grain), followed by a 
saline purge. The room should be at an equable 
temperature, not lower than 65° F. 
1$. Tincture of aconite, np xxx 
Tincture of belladonna, rr[ xxx 
Glycerin, 3 ij 
Solution of potassium citrate, 
enough to make 3 ij. 
Two teaspoonfuls every 3 hours. 
Hot foot-baths taken at bedtime are of great 
benefit. The water should be as hot as can be 
borne, and applied by means of a towel as high up 
as the knees. From 10 to 15 minutes may be well 
spent in this manner. If necessary, it may be 
repeated again during the night, and for several 
successive nights. Diaphoresis may be encour- 
aged by the use of hot drinks, with 5-grain doses of 
quinin and a Dover's powder. The diet at all 
times should be light and nourishing. Under 
no circumstances should constipation be allowed 
to exist. 
Diuretics are also advisable; the solution of 
potassium citrate is particularly serviceable. It 
may be combined with 2-drop or 4-drop doses of 
tincture of aconite. 
Local Treatment.-Small pieces of ice may be 
allowed slowly to dissolve in the mouth; exter- 
nally, cold cloths. Leiter's coil or rubber tubing, 
through which cold water is allowed to run, may 
be applied. 
Sedative inhalations are valuable: 
1$. Menthol, gr. ij 
Chloroform, 3 ss 
Compound tincture of ben- 
zoin, enough to make 3 ij. 
Two teaspoonfuls to a pint of hot water, and 
inhale every two hours. 
For the first 2 or 3 days the throat may be swab- 
bed out once daily with glycerite of tannin or 
boroglycerid. 
Acute laryngitis in children is best relieved by the 
administration of syrup of ipecac (1/2 of a dram) 
every 15 minutes until vomiting occurs. Exter- 
nally, the throat may be thoroughly lubricated 
with benzoinated lard, containing a small amount 
of oil of mustard. The parts may be covered with 
hot flannel cloths, frequently repeated. If there 
is a tendency to recur, the throat may be swabbed 
with glycerite of tannin. 
LARYNGITIS, CHRONIC. Varieties.-Simple 
chronic catarrhal laryngitis; (2) tubercular laryn- 
gitis; (3) syphilitic laryngitis. 
Simple Chronic Catarrhal Laryngitis. 
Synonym.-Chronic laryngeal catarrh. 
The etiology is the same as acute laryngitis. It 
may follow acute attacks. 
Pathology.-Cellular infiltration and hypertro- 
phy of the mucous membrane, with permanent 
dilatation of the blood-vessels, is the distinct lesion. 
The glandular structure becomes involved, forming 
slight elevations (granulations), giving rise to 
what is termed follicular laryngitis. Generally 
the surface is red and swollen, and covered with 
thick mucus. Superficial erosions may occur. 
The vocal bands may contain small nodules. 
Symptoms.-Tickling in the throat, hoarseness, 
persistent cough, and expectoration of thick, 
tenacious, whitish mucus are the most common 
symptoms. Physical examination reveals con- 
gestion of the larynx, with small granulations in 
certain portions of the mucous membrane. The 
vocal bands are usually reddened, frequently 
unilateral, or the cartilaginous portion alone may 
be affected. 
Prognosis is guardedly favorable under prolonged 
treatment. 
General Treatment.-Correct the indigestion, 
constipation, and restrict the use of tobacco and 
alcoholic drinks. Tonics, such as the syrup of 
hypophosphites with iron and strychnin, are 
valuable. Turkish baths are of benefit. 
Local Treatment.-Erosions or enlarged follicles, 
after being cocainized, should be removed by 
means of molded silver nitrate or the galvanocau- 
tery. Stimulating inhalations are of service. 
1$. Eucalyptol, gr. iij 
Spirit of camphor, 5 iv 
Compound tincture of 
benzoin, enough to make 3 ij. 
Two teaspoonfuls to a pint of hot water. In- 
hale on rising and at bedtime. LARYNGITIS, CHRONIC 
LARYNGITIS, EDEMATOUS 
After the morning inhalation it is best for the 
patient to remain indoors for an hour or two. 
Local applications of a solution of silver nitrate 
(10 to 20 grains to the ounce) may be applied 
twice a week. Glycerite of tannin, or boroglycerid 
(50 percent), may be substituted for the silver 
nitrate. Cleanse the throat at intervals by means 
of alkaline solutions, used in the form of a spray. 
Solutions made from any of the antiseptic nasal- 
douche tablets may be employed for this purpose. 
See Rhinitis (Chronic). Guaiac has been recom- 
mended. It is best administered in the form of a 
lozenge. 
3. Guaiac, 3 ij 
Oil of cloves, ' m ij 
Oil of lemon, n; v 
Powdered acacia, 3 ss 
Powdered sugar, 3 j 
Confection of rose, enough to make 30 
lozenges. 
Allow one to dissolve in the mouth every 4 
hours. 
Prognosis.-See Tuberculosis. 
General Treatment.-See Tuberculosis. 
Local Treatment.-Cleanse the parts once or 
twice a week with an alkaline spray, and sub- 
sequently dust over with aristol or iodoform. If 
the pain is intense, touch the ulcers with a solution 
of cocain (10 percent). Menthol may also be used 
for the same purpose. 
To be inhaled: 
1$. Menthol, gr. iij 
Creosote (beechwood), xvj 
Compound tincture of 
benzoin, § ij. 
Two teaspoonfuls to a pint of hot water. In- 
hale at bedtime. 
Weak solutions of menthol in albolene used in a 
nebulizer give good results. 
More profound and prolonged anesthesia may, 
however, be produced by the application of a 20 
percent solution of quinin and urea hydrochlorid 
(q. v.); which has recently been highly praised. 
Electric cataphoresis with guaiacol or oxychlorid 
of copper has proved of value. Submucous and 
intratrachial injections of guaiacol, 20 percent, are 
sometimes efficacious. 
Edema of the larynx frequently occurs, and 
tracheotomy is occasionally advisable. 
Tuberculous Laryngitis. 
This is usually secondary to pulmonary tubercu- 
losis. 
Symptoms.-Hoarseness, pain on deglutition, 
distressing cough, hemoptysis, and frequent 
attacks of aphonia. 
Physical examination reveals a marked paleness 
of the mucous membrane of the larynx and vocal 
cords, ulceration, and distinct hypertrophy (ex- 
crescences) of the glandular structure in localized 
areas. Caries and necrosis may be present. 
The ulcers are multiple in character and have 
a tendency to coalesce without much tendency to 
penetrate deeply. 
Tuberculous laryngitis and syphilitic laryngitis 
may be differentiated as follows: 
Syphilitic Laryngitis. 
Symptoms.-There is peristent huskiness of 
voice. The cough is less troublesome than in the 
tuberculous form, and pain is not great or may be 
entirely absent. 
Physical Examination.-The larynx is ulcerated, 
the vocal cords congested, and mucous patches 
may appear on the tip of the epiglottis or on the 
ventricular bands. The latter are described by 
Gottstein as being "round or elongated grayish- 
white spots of thickened epithelium, slightly raised 
upon the congested tissue which surrounds them, 
and are either sharply circumscribed or shade 
gradually off into it." The secretion is scanty and 
very tenacious. 
Complication.-Edema of the larynx is very 
common. 
General Treatment.-See Syphilis. 
Locally, the ulcers may be touched with the 
galvanocautery, a solution of zinc chlorid (30 
grains to 1 ounce), or with a crystal of copper 
sulphate or silver nitrate. Stimulating inhala- 
tions may be used. 
Should edema of larynx occur, tracheotomy 
may be necessary. 
LARYNGITIS, EDEMATOUS (Edema of the 
Glottis).-An acute inflammation of the mucous 
membrane of the larynx and that about the 
glottis, with an infiltration of the areolar tissues 
by a serous, seropurulent, or purulent fluid; it is 
characterized by obstructed or stridulous breathing 
and dysphonia or aphonia. 
Etiology.-It may be the result of acute laryngi- 
tis; abscess in or about the throat or tonsils; erysip- 
elas of the face; scarlatina; small-pox; Bright's 
Tuberculous Laryn- 
gitis 
Pain severe on degluti- 
tion. 
Ulcerates slowly. 
Usually first appears as 
small spots or nodules 
which are rapidly fol- 
lowed by great edema. 
Ulcers extend laterally, 
but not deeply. 
Mucous membrane is 
usually pale. 
Health impaired p r e- 
vious to laryngeal 
involvement. 
Previous or coincident 
pulmonary trouble 
common. 
lodids have no influence. 
Syphilitic Laryngitis. 
Usually slight. 
Rapidly. 
Is rarely seen in stage 
of induration, the 
first evidence being 
a clear-cut, deep 
ulcer. 
Extend deeply, often 
involving cartilage. 
Hyperemic, injected. 
Unimpaired. 
Frequently evidence 
of syphilitic disease 
in other tissues. 
Readily improves 
under iodids. 
Complication.-Edema of the larynx is very 
common. LARYNGITIS, EDEMATOUS 
LARYNGOTOMY 
disease; syphilis of the larynx. It is rare in 
children, except when due to scalds. 
Pathologic Anatomy.-There is infiltration of the 
loose connective tissue of the aryepiglottic folds, 
the glossoepiglottic ligament, the base of the epi- 
glottis, and the interarytenoid space. If the true 
vocal bands are inflamed, their color changes, and 
instead of appearing white, glistening, and bril- 
liant, they are dull, grayish-red, or violet-red in 
patches. If the swelling is the result of purulent 
infiltration, the parts affected present a deeply 
congested color, with here and there spots of a 
yellowish hue. Serous infiltration, sufficient to 
cause fatal edema, disappears with death, leav- 
ing But slight traces to account for the formidable 
symptoms. 
Symptoms.-The onset is much the same as a 
simple catarrhal laryngitis with a gradually 
increasing impediment to the respiration. The 
patient experiences the sensation of a foreign body 
in the throat, and, after a short time, a difficulty 
of breathing, which ultimately threatens suffoca- 
tion. The deglutition is rendered difficult owing 
to the swelling of the epiglottis. The voice, at first 
muffled, gradually becomes weaker and weaker, 
until finally it is almost extinct. The cough 
at first is dry and harsh, but as the infiltration 
increases it becomes stridulous and suppressed; 
there is no expectoration except that, after great 
effort to clear the throat, a little frothy mucus 
is raised. The difficulty of respiration, as the 
disease progresses, becomes greater and greater, 
and the paroxysms of impending suffocation more 
frequent. The inspiration is accompanied by a 
whistling sound characteristic of the narrow 
condition of the glottis; the patient sits up in bed, 
his mouth open, gasping for breath, his eyes pro- 
truding, the whole body trembling with intense 
convulsive movements; after a time a general 
cyanosis commences, the face assuming a bluish 
hue, all these symptoms continuing for a few 
moments, when slight relief occurs, to be again 
followed by another paroxysm, in one of which, 
if nature or art does not afford prompt relief, 
death occurs from asphyxia. A physical examina- 
tion of the parts may be made by gently passing 
the finger into the throat, when the epiglottis 
may be felt very much thickened, and the ary- 
epiglottic folds may have attained such tume- 
faction as to convey to the finger an impression 
similar to that which is given by touching the 
tonsils. 
Laryngoscopic Appearance.-The mucous mem- 
brane has a bright-red appearance. The epiglottis 
has the appearance of a semitransparent, roll-like 
body, or it is often merely erect and tense. It is 
this condition of the epiglottis which explains 
the pain and difficulty in deglutition. Rarely 
the vocal bands are infiltrated. 
Diagnosis.-Any disease which gives rise to 
dyspnea may simulate edematous laryngitis, but 
the history of the case, together with a laryngo- 
scopic examination, will generally furnish con- 
clusive evidence as to the real nature of the malady. 
Prognosis is, as a rule, unfavorable. If early 
and vigorous treatment is instituted, recovery 
is possible; but without it death is the inevitable 
result, the patient dying asphyxiated. Even 
when local measures have removed the obstruction 
to free respiration, the patient is very likely to 
perish subsequently from exhaustion or blood- 
poisoning, or from pneumonia or other lung 
complication. The duration of infiltration of the 
larynx varies from a few hours to several days. 
Treatment.-Prompt local treatment must be 
adopted in order to remove the laryngeal obstruc- 
tion. A blister or leeches placed over the sides 
of the larynx in mild cases may effect so much 
reduction in the edema as to free the patient from 
danger. 
If the infiltration has already occurred, and 
is slight in amount, scarification, guiding the in- 
strument by the index-finger of the opposite 
hand, may afford relief, or the hypodermic in- 
jection of pilocarpin, 1/3 of a grain, repeated, may 
lessen the swelling. 
The persistent use of small pellets of ice, swal- 
lowed or held far back in the mouth until dissolved, 
early in the attack and the application of ice to 
the neck; the administration of saline laxatives; 
the inhalation or spray of alum, adrenalin, or a 
strong solution of tannic acid; and the application, 
as near the seat of the disease as possible, of 
Monsel's solution, full or half strength, may be 
effective. Mackenzie says the patient should be 
kept constantly under the influence of potassium 
bro mid. 
If these means fail, tracheotomy or intubation 
is indicated; in those cases of sudden and rapid in- 
filtration of the glottis or larynx occurring in 
Bright's disease, erysipelas, scarlatina, or syphilis 
of the larynx, and especially the former and the 
latter, tracheotomy or intubation should be per- 
formed at once. 
In all cases of infiltration of the larynx stimulants 
should be boldly administered by the rectum, 
if stomachic administration is impossible. If the 
infiltration is composed of pus, quinin sulphate, 
5 grains every 4 hours, and stimulants are in- 
dicated. See Laryngitis, Tracheotomy, Intu- 
bation. 
LARNYGOSCOPE.-See Larynx (Examination). 
LARYNGOTOMY. Indications-The opera- 
tion of laryngotomy is now rarely performed by 
laryngologists, because of their skill in operating 
within the larynx through the mouth; yet with 
surgeons less skilled in laryngology, and, perhaps, 
more efficient in general operating, laryngotomy 
continues in favor. It must be remembered, how- 
ever, that it is a serious operation, and especially 
dangerous in young children and the aged. It 
is indicated for the removal of neoplasms and 
foreign bodies in the larynx, provided there is 
danger to life from suffocation or dysphagia, and 
when they cannot be removed through the mouth; 
also, in some instances, for the relief of stenosis 
resulting from diphtheria, when other measures 
fail. In cases in which laryngeal tumors are very 
large or very numerous, or, when single, are at- 
tached in places difficult to reach, laryngotomy is 
probably easier than intralaryngeal operation, and 
sometimes it may be safer and more complete. LARYNGOTOMY 
LARYNGOTOMY 
Impacted jagged foreign bodies often demand 
laryngotomy, and others usually require trache- 
otomy. In any case the operation to be pre- 
ferred, provided the operator is competent, should 
only be decided upon after an accurate diagnosis, 
unless suffocation is imminent, and then trache- 
otomy should be done. 
The history and symptoms can seldom be relied 
upon in making an. accurate diagnosis of surgical 
affection of the larynx. In supposed 
cases of foreign bodies in the larynx due 
attention must be given to the state- 
ments and sensations of the patient; yet 
they are often very misleading, so that 
inspection is necessary in most cases. 
Laryngoscopy is difficult, and sometimes 
impossible, in nervous children and in 
some adults. When the throat is very 
irritable, the sensitiveness may generally 
be relieved by the use of a cocain spray. 
But in young children in order to inspect 
the larynx one will often be obliged to 
give an anesthetic and then employ Ker- 
stein's autoscope. Even this will fail to 
reveal the parts in some cases, and then 
we must rely upon the symptoms and 
history for our diagnosis. 
The symptoms of foreign bodies in the 
larynx vary greatly with the position, 
size, and shape of the object, ranging from 
a slight irritation, and including par- 
oxysmal cough, dyspnea, dysphagia, 
and hemorrhage, to clonic spasms of the glottis and 
speedy death. The usual symptoms of a tumor 
in the larynx-varying, of course, with its size 
and shape-are cough, dyspnea, dysphonia 
Supra thyroid laryngotomy is performed by making 
a transverse incision through the superficial struc- 
tures and the thyroid membrane. This incision gives 
but a limited exposure of the cavity of the larynx, 
and the operation is seldom employed, as by it no 
more can be accomplished than through the mouth. 
The infrathyroid method is seldom resorted to 
unless combined with division of some of the upper 
rings of the trachea. 
Laryngeal Incision. 
a. Median subhyoid pharyngotomy, b. Thyrotomy, and, point below, 
laryngotomy. c. High tracheotomy, d. Low tracheotomy, e. The inter- 
rupted lines mark the incisions in laryngectomy.-(Spencer and Gask.) 
Thyrotomy consists of the division of the thyroid 
cartilage in the median line, and is the operation 
commonly referred to as laryngotomy. 
If there is great embarrassment of respiration 
or if much bleeding is feared from the opera- 
tion within the larynx, a preliminary tra- 
cheotomy should be performed and a proper 
tube inserted and left in place. This 
insures free respiration and allows the upper 
part of the trachea or lower part of the 
larynx to be packed with gauze in case 
troublesome hemorrhage is encountered 
within the larynx. Several days, or, better, 
one or more weeks, should generally elapse 
before the more serious operation of thyrot- 
omy is undertaken, though sometimes it is 
best to do both operations at the same time. 
In the interim the surgeon may endeavor 
from time to time to remove the growth 
or foreign bodies by endolaryngeal means 
or through the tracheal opening; or success 
may possibly be attained by the aid of 
Kerstein's autoscope. 
For thyrotomy the patient should be 
anesthetized, and if tracheotomy has been 
previously performed, a rubber tube may 
be attached to the cannula within the tra- 
chea and the anesthetic administered through 
the tube, out of the operator's way. The 
patient should be in the dorsal recumbent posi- 
tion, with the head hanging over the end of the 
table, supported by an assistant or by the knees 
of the operator. 
An incision is made exactly in the median line, 
Situation for Incision in the Middle Line of the Neck. 
a. Subhyoid pharyngotomy, b. Thyrotomy. c. Laryngotomy. d. 
Tracheotomy above isthmus, e. Tracheotomy below isthmus. 
The lines only show the relative situation of the incisions, not their 
correct length.-(Spencer and Gask.) 
or aphonia, and dysphagia. There is also slight 
pain in some cases. 
Operation.-Laryngotomy includes suprathyroid 
laryngotomy, thyrotomy, and infrathyroid laryn- 
gotomy. LARYNX, EXAMINATION 
LARYNX, FOREIGN BODIES 
from the hyoid bone to just below the cricoid 
cartilage, dividing everything down to the thyroid 
cartilage. The soft parts should be retracted and 
all hemorrhage arrested. The thyroid cartilage 
now remains to be divided. In children this 
can easily be done with a strong knife or scissors. 
In adults if ossification has taken place, a small 
circular saw revolved by a motor, a convex saw7, 
or bone-forceps will be found satisfactory. Care 
must be taken to cut exactly in the median line, 
and thus avoid the vocal bands, which are attached 
on either side. It is advantageous to leave a little 
of the upper part of the thyroid cartilage intact, 
in order to avoid displacement of the vocal cords 
in suturing the edges of the wound. The greatest 
difficulties of the operation begin when the larynx 
is opened. Violent reflex action is set up from the 
introduction of the knife or blood into the larynx, 
which rises and falls rapidly and spasmodically. 
A sharp-pointed knife is therefore dangerous at 
this stage of the operation. When this reflex 
action interferes greatly with the progress of the 
operation, it may be checked, in a measure, at 
least, by spraying a 10 percent solution of cocain on 
the laryngeal mucous membrane. Hemorrhage 
is seldom marked, save in cancerous growths. 
Compression is usually sufficient to arrest what 
bleeding there is. 
If operating for a tumor, the larynx may now 
be tamponed below the growth, as suggested for 
the prevention of the entrance of blood into the 
trachea. 
The divided cartilages having been retracted, 
the growth or foreign body is removed. To 
remove neoplasms several differently shaped 
slender forceps, cutting forceps, sharp spoons, 
a snare, porte-caustique, and pointed cautery 
electrodes should be at hand. These must be used 
with great care, so as to preserve as much of the 
mucous membrane of the part as is compatible with 
thorough removal of the tumor. The base of the 
tumor should be cauterized with the gal vanocautery 
or with solid nitrate of silver. Mackenzie prefers 
the latter, believing this practice less likely to be 
followed by laryngitis. The foreign body or 
tumor having been removed, the larynx should 
be gently sponged, to remove all foreign substance, 
and the divided cartilages carefully approximated 
and sutured, preferably with silver wire. 
If tracheotomy has been performed, the tube 
should be left in the trachea until all danger of 
edematous laryngitis is past. 
Removal of a papilloma is not infrequently 
followed by recurrence, but the operation may be 
repeated with a good hope of permanent cure'. 
Malignant growths are, of course, liable to return, 
and the operation for their removal is useless, 
except when the growth is very small and dis- 
tinctly circumscribed. See Neck (Injuries). 
LARYNX, EXAMINATION.-The larynx is the 
organ of voice placed at the upper part of the air- 
passage. It is situated between the trachea 
and base of the tongue, at the upper and anterior 
region of the neck. On each side of it lie the great 
vessels of the neck; behind it forms part of 
the boundary of the pharynx, and is covered 
by the mucous membrane lining that cavity 
(Gray). 
Physical Examination of the Larynx (Laryn- 
goscopy).-For this is needed (1) sunlight or light 
from a student-lamp or an Argand or Welsbach 
gas-burner; (2) a head-mirror with an aperture in 
center; (3) two sizes of laryngeal mirrors; (4) a 
tongue-depressor; (5) a throat applicator; (6) 
a solution of cocain (5 percent or 10 percent). 
The patient is seated facing the examiner, with 
the light behind or on either side of the head and 
on a level with the eye of the operator. After 
anesthetizing the posterior vault of the pharynx 
and soft palate with a solution of cocain (5 percent), 
the tongue is then grasped firmly between the folds 
of a napkin and withdrawn a sufficient distance so 
as to expose the vault of the pharynx, and the light 
is then reflected by means of the head-mirror. It 
is essential that the operator should always look 
through the central opening of the mirror, instead 
of from above or below. 
The laryngoscopic mirror is then slightly heated 
(to prevent the image from becoming cloudy from 
the moisture given off during respiration), and 
slowly introduced until the posterior vault of the 
pharynx is reached. Care should be exercised 
not to touch any portion of the vault of the pharynx, 
tongue, or of soft palate not anesthetized, as it 
would cause retching, and often vomiting. The 
patient is then directed to slightly tilt the head 
backward and to phonate "a" or "ee." 
The first examination is often unsatisfactory, 
from the fact that the fear of the patient is aroused 
LARYNX, FOREIGN BODIES.-It not infre- 
quently happens that children, place various arti- 
cles in their mouth, and then by aspiration draw 
them into the trachea, instead of swallowing 
them, as was purposed. Such accidents are not 
infrequent with beans, peas, cherry-pits, almonds, 
candies, pennies, tacks, corks, etc. 
The symptoms are violent coughing and suffoca- 
tion, with cyanosis, attending the entrance of a 
foreign body into the larynx, and if it remains, 
an irritating cough persists with subsequent 
inflammation and ulceration of the trachea. 
Should the substance be carried deeper, we may 
be able to perceive its irritating motion as an 
audible gurgling sound, to and fro with each 
respiration. Or if it is lodged fast, as might hap- 
pen with a sharp bit of bone, it produces localized 
ulceration, indicated by a cough attended with 
bloody or purulent sputum. Should the body be 
drawn still lower down into the smaller bronchioles, 
it may lead either to atelecetasis of that portion 
of the lung or to pneumonia. 
Some of these foreign bodies, as needles, may 
migrate to other parts of the body, or they may 
result in abscesses, or may, more rarely, become 
encapsulated. Small, soft bodies, like bits of 
meat, may be thrown out by violent coughing or, 
if soluble, like candy, may be dissolved. 
The prognosis is generally unfavorable if the 
foreign body has passed within the vocal bands or 
if the body is too large to be coughed out or dis- 
solved. An insoluble foreign body inspired into 
one of the lesser bronchioles leads almost inevit- LARYNX, TUMORS 
LATIN, MEDICAL 
ably to death, as there is no operative or medicinal 
measure that can be safely used for its removal. 
Treatment.-If the foreign body lies above the 
vocal bands, its extraction should be attempted as 
speedily as possible, with the aid of the appropriate 
instruments, or, if these are not at hand, by hold- 
ing the child by its heels, head downward, and 
encouraging coughing by slapping its back or tick- 
ling its fauces. When the offending substance has 
gone deeper, we must resort, first, to forcible ex- 
piration following long-drawn inspirations (forced 
coughing) and emetics, the promptest of which is 
apomorphin (1/12 of a grain) or turpeth mineral 
(1 grain). Tracheotomy is called for when the ob- 
ject can be localized, and this operation is usually 
successful. See Laryngotomy, Tracheotomy. 
LARYNX, TUMORS.-The most frequent benign 
tumors observed are first, papillomata, second, 
fibromata. They should be removed under local 
anesthesia by the intralaryngeal method if pos- 
sible, the laryngeal forceps, the cutting forceps, 
the cold wire or galvanocautery snare being used. 
In children, and for large growths tracheotomy 
may be detnanded. 
Malignant growths are usually epitheliomata. 
Rarely sarcoma occurs. In the case of a sarcoma 
the preliminary tracheotomy, which is desirable 
in every instance, generally reveals the necessity of 
a complete laryngectomy. Epithelioma usually 
originates in a vocal cord, in old or middle aged 
men and is of slow development. There may be 
a history of chronic inflammation or of overuse of 
the voice. The first symptom is hoarseness. Mi- 
croscopic examination of a piece of the growth may 
not be feasible. In some cases, indeed, there is 
danger of metastasis and stimulation of the growth 
resulting from removal of a piece of tissue, and a 
negative report is often misleading. Tuberculosis 
and syphilis may be eliminated by the tuberculin 
test and large doses of potassium iodid. One or 
the other of these diseases, however, may coexist 
with the epithelioma. 
Palliative treatment consists in relieving the 
pain with local anesthetics and, as a last resort, 
morphin. The frequent application of adrenalin 
and the ligature of the laryngeal arteries possibly 
may control the growth. Radical treatment in- 
cludes thyrotomy, with a primary tracheotomy, 
followed by free excision of all the diseased tissue. 
LATERAL SCLEROSIS, PRIMARY (Spastic 
Spinal Paralysis of the Adult, Primary Spastic Para- 
plegia, Spasmodic Tabes Dorsalis).-A chronic 
disease of the spinal cord characterized by para- 
plegia, contractures of the muscles, with exagger- 
ated reflexes, but without sensory or vesical dis- 
turbances or atrophy. A disease of early adult 
life, generally between 20 and 40, occurring very 
rarely in children. The etiology is obscure. It has 
been traced to syphilis, trauma, lead-poisoning, 
acute infectious fevers, and the puerperium. The 
lesion is essentially in the pyramidal tracts. The 
onset is marked by a sense of heaviness and 
weakness in the legs. 
Symptoms.-There is gradual loss of power in 
the muscles combined with rigidity. The spasms 
of the legs gradually increase in extent as the 
power lessens, until at last the legs, whenever ex- 
tended, pass into a condition of strong extensor 
spasm, rigidly fixing them to the pelvis, so that 
the patient lies rigid; if one leg is lifted from the 
couch by the observer, the other leg is moved 
also. The spasm may be such that the knee can- 
not be passively flexed by any force that can be 
applied to it until the spasm has become less. 
When flexed, the limb is comparatively supple; 
but if it is then extended, the spasm instantly re- 
turns, making the limb rigid, and often completing 
the extension, just as the blade of a knife opens 
out under the influence of its spring-" clasp-knife 
rigidity." Occasionally there occur brief flexor 
spasms, drawing the legs up. The tendon and 
superficial reflexes are markedly exaggerated 
(Babinski's sign and ankle clonus are easily elic- 
ited.) The spastic gait is characteristic, termed 
by Hammond "the waddle"; the legs drag behind 
and are moved forward as a rigid whole, the toes 
catching against the ground, the patient showing 
a tendency to fall forward. Sensation is unaf- 
fected. As the morbid process extends upward, 
the superior extremities suffer in the same manner 
as those of the lower. The reaction of degenera- 
tion is absent. 
The disease may be long protracted, but is in- 
curable. Treatment consists in rest, massage, 
warm baths. Treatment should be directed to the 
improvement of the general health. If syphilis 
is present, mercury and the iodids are indicated. 
Electricity may be tried. 
Hysterical spastic paraplegia simulates the true 
form, but some hysterical stigmata may appear on 
careful examination. Recovery may take place 
under proper treatment. 
LATHYRISM.-See Lupinosis. 
LATIN, MEDICAL.-The verbs used in prescrip- 
tion-writing are nearly all in the imperative mood, 
giving directions to the compounder, and having 
their object in the accusative case. Such are: 
Adde, add. 
Cola, strain. 
Divide, divide. 
Extende, spread. 
Fac, make. 
Filtra, filter. 
Macera, macerate 
Misce, mix. 
Recipe, take. 
Signa, write. 
Solve, dissolve. 
Tere, rub. 
A few verbs are found in the subjunctive mood, 
taking their subject in the nominative case. The 
most usual are: 
Fiat, let be made. 
Coletur, let be strained. 
Coloretur, let be colored. 
Bulliat, let boil. 
Detur, let be given. 
Dividatur, let be divided. 
Sit, let it be. 
Sumatur, let be taken. 
Participles or verbal adjectives are occasionally 
used, and should agree with their respective nouns 
in gender, number, and case. Such are: 
Capiat, let take. 
Adhibendus, a, um, to be administered. 
Dividendus, a, um, to be divided. 
Sumendus, a, um, to be taken. 
Prepositions.-The accusative case follows those 
in the first column, the ablative those in the second 
column: LAUDANUM 
LAVAGE 
Ad, to, up to. 
In, into. 
Supra, upon. 
Cum, with. 
Pro, for. 
Sine, without. 
desired. It is the form of opium mostly used in 
liniments, and for external applications, as with 
lead-water. See Opium. 
LAUGHING GAS.-See Nitrous Oxid, Anes- 
thetics. 
LAVAGE.-Irrigation or washing out of the 
stomach. 
Uses.-Lavage is more valuable for diagnosis 
than for treatment. In cases of chronic indigestion 
and often in neurasthenia, constipation, insomnia, 
and especially in stubborn headaches, it is of value 
to make an analysis of the stomach-contents under 
varying conditions, to determine exactly what sort 
of work the organ is doing as to its secretory, ab- 
sorptive, and motor functions. When such tests 
show a large amount of mucus, gastric catarrh 
may be suspected; and in most cases of chronic 
catarrhal inflammation of the stomach lavage will 
do good; in many of them it is almost indispensable. 
More often the mucus comes from the parts above, 
having been swallowed; and the diagnosis of 
chronic gastric catarrh, which many physicians 
attempt to make offhand, frequently presents diffi- 
culties, even with the help of chemic and micro- 
scopic examinations of the stomach-contents. See 
Stomach. 
The most imperative indication for lavage is 
gastrectasis, or aggravated dilatation of the 
stomach, whether resulting from narrowing of the 
pyloric orifice (cancer or other tumors, or the cica- 
trix of an ulcer), from a kink of the small intestines 
(which may follow displacement of the stomach, 
colon, or right kidney), or from atony of the mus- 
cular walls of the organ. Whatever the cause, 
dilatation, when neglected, tends to become a 
serious condition, and lavage judiciously done is an 
aid to the cure in the atonic cases, while it is a most 
valuable palliative in the desperate ones until 
operative relief can be obtained. In bad cases of 
gastric catarrh and in patients not too reduced in 
strength, provided all the results are encouraging, 
it will be proper to wash out the stomach every 
day at first, until the amount of mucus is mark- 
edly lessened. This will be the more advisable if 
the microscope shows the presence of numerous 
yeast fungi or sarcinse in the wash-water. As the 
conditions improve, or sooner if the patient should 
fall off in flesh, cardiac tone, or appetite, the inter- 
vals should be prolonged, until by the end of a 
month or two, once or twice a week may often be 
enough. When the treatment has been begun 
early and is properly carried out, one will often suc- 
ceed in removing all the symptoms and signs of 
disease within 2 months; but in very advanced 
or debilitated cases, one will need to be guided 
by the effects, and sometimes, in such cases, a 
radical cure is scarcely practicable outside of a 
special institution. The best that can be accom- 
plished then, under ordinary conditions, is pal- 
liation, and for this it is useful to cleanse away the 
accumulated mucus and bacteria at least once a 
week for long periods (Reed). 
Time.-In nearly all cases the best time for 
lavage is before breakfast. Many good authorities 
advise that lavage should be done at bedtime 
when fermenting food in the stomach prevents 
Ana, of each, governs the genitive case. 
Sundry Words and Phrases in Most Frequent 
Use. 
Bis, twice. 
Bene, well. 
Dein, thereupon. 
Et, and. 
Gradatim, gradually. 
Guttatim, by drops. 
In dies, daily. 
Da, give. 
Non, not. 
Numero, to the number of. 
Numerus, number. 
Octarius, a pint. 
Semel, once. 
Simul, together. 
Statim, at once. 
Ter, thrice. 
Q uater, four times. 
Ad saturandum, to satu- 
ration. 
Quantum sufficiat, as much as necessary. 
Pro re nata, according to need. 
In partes cequales, into equal parts. 
Redactus in pulverem, let be pulverized. 
Secundum artem, according to art. 
Non repetatur, let it not be repeated. 
See Prescription-writing. 
Nom. 
Gen. 
Exceptions. 
a 
se 
Cataplasma, Enema, Physostigma, Aspido- 
sperma, and Gargarysma all have the 
genitive in -atis. Folia is plural; gen., 
Foliorum. 
us 
urn 
os 
on 
1 
Rhus, Rhois; Flos, Floris; Bos, Bovis; 
Limon, Limonis; Erigeron, Erigerontis. 
Fructus, Cornus, Quercus, Spiritus, Haus- 
tus, Potus, do not change, being of fourth 
declension. 
as 
atis 
Asclepias, Asclepiadis; Mas, Maris. 
is 
idis , 
Pul vis, Pulveris; Arsenis, Arseni tis; Phos- 
phis, Phosphitis; Sulphis, Sulphitis; and all 
salts ending in -is have genitive in -it is. 
0 
onis 
Mucilago, -inis; Ustilago, -inis; Solidago, 
-inis. 
1 
-lis 
Fei, Fellis; Mel, Meilis; Sumbul, Sumbuli. 
e 
en 
ps 
rs 
X 
es 
inis 
pis 
rtis 
ris 
cis 
Words which do not change in the 
Genitive. 
Azedarach Ethyl1 Potus 
Buchu Fructus Quercus 
Cannabis Gambir Sabal 
Caoutchouc Haustus Sago 
Catechu Hydrastis Sassafras 
Chloral1 Jaborandi Sinapis 
Cundurango Kino Spiritus 
Curare Matico Sumbul 
Digitalis Menthol1 Thymol1 
Genitive Case-Endings.-(Potter.') 
LAUDANUM.-The tincture of opium, contain- 
ing about 48 grains of opium to the ounce. The 
dose is from 5 to 30 minims, according to the effect 
1 In the B. P. Chloral, Ethyl, Menthol, and Thymol are 
Latin nominatives, and do not change in the genitive, 
(e. g., Syrupus Chloral, Liquor Ethyl Nitritis, Emplastrum 
Menthol). In the U. S. P. the corresponding nominatives 
are Chloralum, .Ethyl, Menthol, and Thymol; but the geni- 
tive of .Ethyl is Ethylis, and that of Thymol is Thymolis, 
(e. g., Ethylis Carbamas, Thymolis lodidum). LAVAGE 
LAVENDER 
sleep. Exceptionally this may be useful, espe- 
cially in cases of gastralgia, but diseased stomachs 
are rarely empty at bedtime, and experience 
teaches that, as a continuous practice, washing 
away half-digested food is disastrous. When 
severe fermentation cannot be otherwise con- 
trolled, it would be better to feed less by the 
stomach and supplement by nutritive enemata. 
Method.-The best and the simplest apparatus 
is a medium-sized tube, though the larger the bet- 
ter, provided the patient tolerates it well. It 
should be long enough to extend 3 feet from the 
mouth. A bulb in the course of it will be helpful 
in case of blocking; and a separate large glass 
funnel holding a pint is much better than the 
small soft-rubber ones that are found attached to 
many of the tubes in the shops. Warm water, ster- 
ilized by boiling, with or without bicarbonate of 
sodium dissolved in it to the extent of 1 or 2 tea- 
spoonfuls to the quart, is used. If there is doubt 
as to the diagnosis, simple boiled water may be 
used. 
When there is a marked deficiency of hydro- 
chloric acid, the water may be hotter, and table 
salt, from a teaspoonful to a tablespoonful, may be 
added to each quart. Exceptionally, stronger 
antiseptics or astringents may be used-alum, 
one-half to a teaspoonful, and silver nitrate, 1 or 
2 grains to the quart, but this should be followed 
with a salt solution after the silver nitrate. The 
patient's garments should be protected with 
towels or oilcloth. If the throat is very sensitive, 
it should be sprayed with a solution of cocain 
(3 or 4 percent) in liquid vaselin, to which has 
been added 1 grain of menthol. 
It is not necessary to lubricate the tube with 
glycerin or vaselin, but it may be dipped in water. 
The process of introduction must be an educative 
one, and the first trial may fail. 
The patient should sit in a low chair with his 
head thrown back; the mouth should be opened 
about two-thirds its full width, and the patient is 
instructed to breathe naturally. The index- 
finger of the operator is then inserted well back 
into the pharynx, and the tube is pushed along 
the side of the finger to the posterior wall of the 
pharynx and down into the entrance of the esopha- 
gus; the patient is then instructed to swallow, at 
the same time gradually pushing the tube onward 
until it has entered the stomach. The average 
distance from the incisor teeth to the lower border 
of the stomach is 22 inches. In gastric dilatation 
it is more than this. 
The tube, with the funnel inserted in it, having 
been introduced, the solution, previously prepared 
and placed in a pitcher at hand, is poured in, a 
pint or quart at a time. Just before the last of 
the water has disappeared from the funnel the 
latter should be carried quickly down toward 
the floor and held in the inverted position over a 
pail. By siphonage the liquid now flows back 
into the inverted funnel, where it may be in- 
spected before emptying. A piece of glass tubing 
inserted at some point of the tube outside the 
mouth, or between two sections of the tube, will 
enable one to see when the liquid is flowing through 
properly. One quart of water is quite as much 
as most patients will care to have used in the first 
washings, but later the quantity may be gradually 
increased, until finally several quarts, or enough 
to cleanse away all the mucus, may be introduced; 
but not more than 1 quart at a time, and in some 
very weak stomachs a pint at a time, will be 
more advisable. It has been found that to lessen 
considerably the time required to loosen and 
detach all the mucus in old gastric catarrhs it is 
advisable to have the patient drink a cup or two 
of warm water before taking the tube, and then, 
lying down on the back, make voluntary contrac- 
tions of the abdominal muscles so as to splash 
the water around in the stomach for 3 to 5 minutes. 
When this is done, scarcely one-half the usual 
quantity of water is required in the washing out, 
which follows directly afterward. Delicate patients 
should be allowed to rest in the recumbent position 
half an hour at least after lavage, and in no case 
should a meal be eaten within that time after the 
procedure. 
The tube should be withdrawn gradually while 
the patient is in a sitting posture. 
Lavage in Infants.-Lavage is a very valuable 
therapeutic measure in infants. In children over 
18 months or 2 years of age it is more difficult 
of application and not, as a rule, useful. The 
indications for stomach-washing are acute in- 
digestion, either with or without persistent vomit- 
ing, when a single washing may be sufficient; 
and certain cases of chronic indigestion when daily 
washing is necessary, and in poisoning. 
Apparatus and Method.-A soft-rubber catheter 
connected by a short glass tube to a piece of rubber 
tubing and a glass funnel, as described under 
Gavage (q. v.), are all the apparatus necessary. 
The catheter should be as large as can be easily 
passed (about No. 24 French), and should have 
one or more large eyes. The child should be held 
in the sitting position and its body protected by 
a rubber sheet. The tongue is depressed with the 
forefinger of the left hand, and the catheter 
moistened and passed rapidly back into the phar- 
ynx and down the esophagus. About 10 inches of 
the catheter should be passed beyond the lips. 
When the stomach is reached, the funnel is 
momentarily raised to allow the gas to escape, 
then lowered in order to siphon out any fluid 
which may be in the stomach. If nothing escapes, 
the funnel is raised and from 4 to 6 ounces of 
water poured into it, when the funnel is again 
lowered and the water siphoned out. This pro- 
ce,dure is repeated from 4 to 10 times or until the 
water returns perfectly clear. Boiled water 
should be used at 100° to 110° F.-the higher tem- 
perature when there is great gastric irritation. 
It is not often advisable to add anything to the 
water, but in some cases a weak solution of boric 
acid or a salt solution, a teaspoonful to the pint, 
may be used. 
LAVENDER (Lavandula).-The fresh flowers of 
Lavandula officinalis. They have a fragrant odor, 
and an aromatic, camphoraceous taste; and contain 
resin and tannin, also a volatile oil. 
Lavender is aromatic, stimulant and carmina- LAXATIVES 
LEAD 
tive, but is rarely used alone as a medicine. It is 
an agreeable flavoring and perfume, in the form of 
the official spirit, which is sold under the name of 
lavender-water, after the addition of oil of berga- 
mot and essence of ambergris. The compound 
tincture is a very agreeable combination of spices, 
and is much used as a remedy for gastralgia, 
nausea, and flatulence, and as an adjuvant or cor- 
rigent of other medicines. 
Preparations.-Oleum lavandulae florum, a vol- 
atile oil distilled from fresh lavender, and having 
the fragrant odor of the flowers. It is soluble in 
alcohol in all proportions, in 3 times its volume of 
a mixture of alcohol 3 and water 1, and in glacial 
acetic acid. Dose, 1 to 5 minims. Spiritus L. has 
of the oil 5, in alcohol 95. A perfume and flavor- 
ing agent. Dose, 10 to 45 minims. Tinctura L. 
Composita, an aromatic stimulant, composed of 
the oil 8, oil of rosemary 2, saigon cinnamon 20, 
cloves 5, nutmeg 10, red saunders 10, alcohol 750, 
water to 1000. Is a constituent of Fowler's 
solution. Dose, 10 to 45 minims. 
LAXATIVES.-See Cathartics. 
LEAD (Plumbum).-Symbol, Pb. Atomic 
weight, 207; quantivalence, ii or iv. A bluish- 
white, soft, malleable metal, obtained from a native 
sulphid called galena, by roasting. Soluble salts 
of lead combine with albumin, forming albumin- 
ates. In large doses by the stomach they are 
irritant to the mucous membrane. Upon the 
intestines they act as powerful astringents. If 
absorbed into the circulation in small quantities 
for a considerable period of time, lead causes a very 
interesting and varied group of symptoms, which 
are described below. Lead is eliminated through 
the kidneys and the intestinal mucosa. It appears 
to check the elimination of uric acid, and is, 
especially in England, a factor in the causation of 
gout in lead-workers. In medicine lead is used 
locally as a sedative to inflamed parts, as an 
astringent to mucous surfaces, as in gonorrhea and 
leukorrhea. 
Therapeutics.-Lead salts are chiefly used as 
astringents and hemostatics. The solution of the 
subacetate, diluted with 4 parts of glycerin and 
water, is locally employed in many skin-diseases, 
especially in eczema, lichen, impetigo, and ery- 
thema; also in catarrhal discharges of mucopuru- 
lent character from the ear, vagina, and urethra, 
particularly in gonorrhea and leukorrhea. Inflam- 
mations of external parts are constantly treated 
by the lotion of "lead-water and laudanum" 
(liquor plumbi subacetatis dilutus, 7 parts to 1 
of tinctura opii). 
Internally the acetate, in 2-grain doses every 
3 hours, is used in various internal hemorrhages, 
particularly hemoptysis, hematemesis, and gastric 
ulcer. The same salt is used in smaller doses in 
bronchorrhea, and with powdered opium if there 
are choleraic symptoms, and still smaller doses for 
the summer complaint of children. In caseous 
pneumonia and in cardiac hypertrophy, and in 
whooping-cough with excessive bronchial se- 
cretion, and in humid asthma, the acetate is also 
useful. 
The carbonate is useful in erythema, erysipelas, 
intertrigo, and as white paint, mixed with linseed 
oil, applied to burns or scalds only when the cuticle 
is unbroken. 
The iodid is useful as an ointment for enlarged 
lymphatic glands and enlarged spleen, and in 
chronic eczema and psoriasis. The nitrate is 
serviceable when applied to fissured nipples, 10 
grains to 1 ounce of glycerin. In solution it is 
deodorant to the fetor of gangrenous sores, ozena, 
and other offensive discharges. 
Acute poisoning is rare, as the salts of lead are 
not often chosen by the intending suicide. It is 
treated by encouraging emesis and washing out the 
stomach. Dilute sulphuric acid, 30 minims in 
water, or the sulphate of magnesia or soda, 1/2 of 
an ounce, should at once be administered, all well 
diluted with water. Milk or the white of egg is 
to be freely given. Morphin given hypodermically 
and poultices may be employed. A subsequent 
course of potassium iodid is advisable. 
Chronic poisoning is called saturnism or plumb- 
ism. It is most common in those whose occupa- 
tion exposes them to contact with salts of the 
metal, such as painters, glaziers, workers in white- 
lead works, etc. Drinking-water and foods may 
also convey the poison to the system; so may 
cosmetics impregnated with lead; indeed, the 
sources of poisoning are manifold and often very 
curious. 
The forms of chronic lead-poisoning may be 
grouped as follows: (1) Lead colic, the most fre- 
quent. The pain is centered about the umbilicus, 
the abdomen is retracted, constipation obstinate, 
the pulse corded. See Colic. (2) Lead palsy, 
wrist-drop or drop-wrist. This is a paralysis of the 
extensor muscles of both forearms; it may be 
associated with sensory disturbances. Paralysis 
of the ocular and the laryngeal muscles has also 
been observed. (3) Saturnine encephalopathy. 
(4) Saturnine arthralgia, a painful affection of the 
joints, especially the knee, rarely the others. 
Objective signs are usually absent. The disease 
may resemble chronic gout. (5) Chronic con- 
tracted kidney. (6) Amblyopia due to atrophy of 
the optic nerve. The general symptoms of lead- 
poisoning are a marked anemia and cachexia, and 
a blue line at the edge of the gums. 
Treatment.-Prophylaxis is of the first im- 
portance, and among workers absolute personal 
cleanliness, extending to the finger-nails, the use 
of a working suit, a daily warm bath after work, 
eating outside the works, and the use of respirators 
are the chief preventive measures. "Treacle 
beer" and sulphuric acid lemonade are beverages 
of service in preventing the effects of the metal. 
Constipation is to be relieved by occasional doses 
of magnesium sulphate. 
Dry, hot fomentations to the abdomen are the 
best application for the lead colic. Magnesium 
sulphate is an excellent purgative, and may be 
administered after the more acute symptoms have 
subsided, in combination w'ith potassium iodid. 
Castor oil, with 5 to 10 minims of the tincture of 
opium added to each dose, is useful to clear the 
bowel. 
Massage is the best treatment for the paralysis LEAD 
LEG, AMPUTATION 
of lead poisoning, and the electric current may be 
applied daily for about 10 minutes. A long 
period of treatment is necessary. 
Incompatible with lead salts are: Alkalies 
mineral acids and their salts, albuminous solu- 
tions, opium, potassium iodid, vegetable acids, 
vegetable astringents, waters containing lime, 
sulphates, carbonates, and carbonic acid gas. 
With lead acetate are: Acids, acetamid, alkalies, 
bromids, carbonates, chloral hydrate, chlorids, 
chromates, cyanids, glucosids, gums, hydrochloric 
acid, iodids, opium, phenol, pyrocatechin, pyro- 
gallol, resorcinol, salicylic acid, sodium phosphate, 
sodium salicylate, sulphates, sulphids, sulphites, 
tannic acid, urea, urethane, vegetable decoctions, 
infusions and tinctures. With solution of lead 
subacetate are: Acacia, acids (organic), albumin, 
alkaloids, antipyrin, glucosids, and otherwise like 
lead acetate. 
Preparations.-P. Acetas {sugar of lead), color- 
less, shining, prismatic crystals or scales, efflor- 
escent, of faintly acetous odor and acid reaction, and 
a sweetish, astringent and metallic taste. Soluble 
in 2.3 of water and in 21 of alcohol at 59° F., in 0.5 
of boiling water and in 1 of boiling alcohol. Dose, 
1/2 to 2 grains. P. lodidum, a heavy, bright, 
citron-yellow powder, odorless and tasteless, fusible 
and volatilizable by heat; soluble in about 2000 of 
water at 59° F., and in about 200 of boiling water. 
Used externally as an ointment. May be given in- 
ternally in doses of 1/5 grain twice daily. P. Ni- 
tras, colorless, opaque, octahedral crystals, odor- 
less, of sweetish, astringent and metallic taste and 
acid reaction; soluble in 2 of water at 59° F., almost 
insoluble in alcohol. Used locally as an astringent 
and deodorizer in solutions up to 1 percent, also 
as an escharotic and a disinfectant. P. Oxidum 
{litharge), a heavy, yellowish, or reddish-yellow 
powder, odorless and tasteless; insoluble in water 
or alcohol, but almost wholly soluble with slight 
effervescence in dilute nitric acid. When heated 
in contact with charcoal it is reduced to metallic 
lead. Used as plaster and sometimes with oil as an 
external application. Liquor P. Subacetatis {Goul- 
ard's extract), an aqueous solution containing 
about 25 percent of the salt, prepared from 
acetate of lead 18, oxid of lead 11, and distilled 
water to 100. It is a clear, colorless liquid, of 
sweetish, astringent taste and alkaline reaction, 
and when added to a solution of acacia it produces 
a dense, white precipitate. Used locally as an 
astringent and cooling lotion, diluted usually with 
an equal quantity of water. Liquor P. Sub- 
acetatis Dilutus {lead water), has of the pre- 
ceding 4, in distilled water to 100. Used locally 
as a mildly astringent and cooling lotion. Cera- 
tum P. Subacetatis {Goulard's cerate) has of the 
solution of lead subacetate 20 percent, with 
camphor 2, wool fat 20, paraffin 20, white petrola- 
tum 38. An astringent application. Emplastrum 
P., has of lead acetate 60, soap 100, each dissolved 
in hot water, mixed, and the liquid decanted. It 
is pliable and tenacious, and forms the basis of 
other plasters. Emplastrum Adhesivum, has of 
rubber 2, petrolatum 2, lead plaster 96. Un- 
guentum Diachylon, has of lead plaster 50, olive 
oil 49, oil of lavender flowers 1. Used locally in 
eczema and other cutaneous disorders. 
LECITHIN.-A phosphorized fat found combined 
with proteids in nervous tissue, yolk of eggs and 
in almost all animal and vegetable cells. The 
lecithins are esters of the fatty acids and glycero- 
phosphoric acid in combination with cholin. 
Lecithin stimulates nutrition, causing an increase 
in the number of erythrocytes and in the per- 
centage of hemoglobin and in the amount of reserve 
proteids. It is believed to be efficient in malnu- 
trition and is said to be especially valuable for 
bottle-fed infants. Dose, 1 1/2 to 8 grains before 
meals in pill form; for infants one-third as much. 
LEECHING.-The use of leeches is indicated 
when it is desired to abstract blood from localities 
which, from their position or from excessive ten- 
derness, are with difficulty operated upon by the 
knife. They are particularly valuable in inflam- 
mations of the eye and ear. In order to imitate as 
near as practicable the conditions under which 
these animals secure their food, the skin over the 
selected locality should be carefully cleansed, 
especially should all traces of soap be removed, 
and of such pungent medicaments as turpentine, 
liniments, etc., otherwise the animals will refuse to 
bite. A little blood or milk smeared upon the skin 
will often induce leeches to take hold. Medicinal 
leeches are of two kinds, the Swedish and Amer- 
ican. The former are much the more powerful, 
and, at least in the treatment of adults, are, as a 
rule, preferred. Each abstracts from 1/2 an 
ounce to 1 ounce of blood. The American leech is 
one-sixth the strength of the European. When a 
number of leeches are to be applied, as over the ab- 
domen in nervous persons, and each bite causes 
alarm, the leeches may be placed in a half glass of 
cold water, and by an adroit movement the glass 
may be inverted on the part; the leeches will 
attach themselves rapidly; the water may be 
drained away and caught in a pledget of absorbent 
cotton. Leech-bites are likely to continue bleed- 
ing. The bleeding may be controlled by pressure, 
Monsel's solution on cotton, styptic cotton, or, 
if these fail, by the application of the actual 
cautery. Leeches should not be applied where 
the skin is delicate or loose, as on the eyelids 
or scrotum. To remove a leech easily, apply a 
small quantity of table salt to it. 
The Heurteloup's apparatus, or artificial leech, 
is of great value when leeches cannot be obtained. 
LEG, AMPUTATION.-Improvements in artifi- 
cial limbs have rendered obsolete the rule that 
made the point of election for amputation of the leg 
three inches below the tubercle of the tibia. Ampu- 
tations just above the ankle, are unsatisfactory 
but unfortunately the teaching of a past era still 
prevails in certain localities. 
The operation is applicable to any portion of 
the leg below the knee-joint to a point within 3 
inches of the ankle. 
The Anteroposterior-flap Operation.-The 2 
flaps are of the same length: that of the anterior 
being cut from without inward, and the posterior 
being procured by transfixion. The patient is 
brought well to the edge of the table; the limb LEG, AMPUTATION 
LEG, FRACTURES 
to be removed is laid upon a pillow, supported at 
the heel by an assistant. The operator places the 
thumb of the left hand on a point just below the 
fibula, and the index-finger a little below the line 
of the internal border of the fibula; with these 
points as guides, a semilunar flap is cut, somewhat 
longer than half the diameter of the limb, through 
the skin and fascia; this is dissected back to the 
points where the index-finger and thumb of the 
left hand rest; a transfixion knife is then entered 
just below the fibula, and being carried through 
the tissues, is made to protrude on the other side, 
opposite the point of entrance, when a posterior 
flap is cut of the same length as that for the ante- 
rior. Any muscles which have not been divided 
are to be severed by a circular sweep of the knife; 
the interosseous space is divided, the periosteum 
pushed back, and the bones sawed through. After 
the limb has been removed, saw off the sharp 
edge of the tibia and cut off 1/2 of an inch of the 
fibula, which insures a better stump. Secure the 
vessels, apply necessary drainage, and close the 
wound in the usual manner. 
Double-flap method, at the upper fourth of the 
leg. A stout bistoury, with blade 4 or 5 inches 
long, and a broad saw are the cutting instruments 
required. The flaps are made of integument 
only, by cutting from the surface without trans- 
fixion. The point of the knife is entered at the 
side, about 2 inches below the tibial tubercle, and 
carried across ithe front of the leg, describing 
an anterior curved flap, somewhat longer than, 
and of the exact width of, the half diameter of 
the limb. This is dissected up close to the bones 
and deep fascia. A similar flap is made on the 
posterior aspect, and the integument and fascia 
composing it are raised from the muscles. The 
latter, with the large vessels and nerves, are then 
divided transversely, direct to the bone. The 
point of the knife must be used to divide the inter- 
vening structures. The bones are then divided 
straight across. 
The anterior tibial artery is often divided as it 
passes between the bones to the front of the leg, 
and it may be difficult to get it separated from the 
surrounding ligamentous structures. 
Single-flap Operation.-The operator places the 
heel of the knife on the side of the limb furthest from 
him, then draws it across the front of the limb, 
cutting a semilunar flap of skin; when its point 
arrives at the opposite side, it is made to trans- 
fix the limb, and then the posterior flap is cut. Care 
must be taken not to get the knife between the 
bones when making the flap by transfixion. The 
muscles and ligamentous structures which are be- 
tween the bones are then divided by the point of 
the knife. The fleshy mass of the gastrocnemius 
may require to be cut out to make the posterior 
flap thinner. 
The Circular Operation is especially adapted to 
removal of the leg at the lower third of its length. 
One assistant supporting the foot and another 
holding the knee, and at the same time drawing 
up the skin, the surgeon makes a circular incision 
through the skin, 4 inches below the point where 
the bones are to be divided. The integument 
is then dissected up for 2 inches and turned back, 
and the muscles divided down to the bone by a 
second or third circular incision. A catling is then 
passed between the bones to divide the interos- 
seous ligament and muscles, and both bones sawed 
through together, the flesh being protected by a 
three-tailed retractor, the middle tail passing be- 
tween the bones; to prevent splintering, the divi- 
sion of the fibula should be completed before that 
of the tibia. The anterior and posterior tibial 
are the principal arteries requiring ligatures. The 
modified circular operation may also be satisfac- 
torily performed at this part of the leg. See 
Amputations. 
LEG, BOW-. See Genu Varum. 
LEG, FRACTURES. Fracture of the tibia at its 
upper end usually results from compression by 
the opposite condyle of the femur, as in falling 
from a height and landing on the feet. The 
symptoms are those of a severe contusion; joint- 
movements are painful, lateral movements usually 
possible, with distinct painful points at the upper 
end of the tibia. Generally the fracture is of only 
one-half of the articular surface, so varus and 
valgus positions are liable to result. 
Treatment is by fixation by splint or weight with 
early massage and movements as in all articular 
fractures. 
Traumatic separation of the upper epiphysis 
of the tibia is rare. It is to be suspected in cases 
of severe contusion at the upper end of the tibia. 
Abnormal mobility and cartilaginous crepitation 
can alone make the diagnosis positive. 
Treatment is on general principles. 
Separation of the tuberosity of the tibia rarely 
occurs. The traction of the quadriceps sometimes 
tears off the tuberosity instead of fracturing the 
patella. The fragment is drawn upward, active 
extension at the knee is impossible, the fragment 
is felt under the skin movable in all directions, 
while the patella is found intact. 
Treatment is very similar to that described for 
fractured patella. See Knee. The joint need 
not be implicated; hence the best treatment is to 
secure the replaced fragment in place by open 
suture. 
Fracture of the shaft of the tibia may occur 
isolated as a result of torsion or bending, being 
transverse, as a rule, in the upper part of the bone, 
and oblique in the lower. 
The symptoms are clear and easily recognized. 
If the fibula remains unbroken and there is much 
longitudinal displacement, the head of the fibula 
must be dislocated upward. This is most likely 
to occur in fracture of the upper half of the shaft. 
If the fibula remains intact and is not luxated, 
marked displacement of the fragments cannot 
well occur. 
Treatment.-If marked swelling has already 
occurred, it is best for a few days to elevate the 
limb in a fracture-box and make local sedative 
applications. The swelling having in a large degree 
subsided, a close-fitting plaster-of-Paris dressing 
is applied, fixing the knee and taking in the foot. 
This dressing should extend to the upper part of the 
thigh and be well padded under the tuberosity of LEGITIMACY, LAWS 
the ischium, which is designed to rest upon it, a 
perineal crutch in this way being provided. A 
2-inch cotton pad is placed on the sole of the foot 
before the plaster is applied. When the patient 
is on his feet, the splint catches the body weight 
on the tuberosity of the ischium, while the foot 
descends into the thick cotton pad mentioned. 
This constitutes the so-called ambulatory splint. 
If there is not great tendency to displacement, 
the patient may be placed on his feet by the end 
of the first week, or even at once, using crutches 
at first and then getting about by the aid of a stick 
alone. It will usually be found necessary to put 
a high sole on the shoe of the sound side. In 4 
weeks the dressing can be removed and a lighter 
one supplied, which is worn for 2 or 3 weeks 
longer, when dressings can be discarded. 
Isolated fracture of the fibula is somewhat rare, 
especially in its middle and upper portions, and it 
is due to direct violence. Fracture at the lower 
end may be due to violent eversion or inversion 
of the foot. There is little tendency to displace- 
ment. 
Treatment.-Plaster-of-Paris is the best dressing. 
The knee need not be fixed. The foot should be 
placed in slight inversion, at a right angle to the 
leg, and fixed in the dressing. 
Fracture of both bones of the leg in the region of 
the diaphysis is a frequent injury, the result of 
direct violence, both bones usually being fractured 
at the same level. Sometimes, the foot being 
fixed and the body twisted, a torsion fracture of 
the tibia results; the weight of the body then falls 
on the tibia, which is broken secondarily and fre- 
quently higher up on the shaft. Oblique fractures 
are, of course, more liable to considerable dis- 
placement, and are relatively less favorable than 
transverse. The lower fragment of the tibia is 
usually displaced upward behind the upper frag- 
ment, and rotated a little outward. This ascent is 
largely due to the action of the calf-muscles. 
This fracture is easy of diagnosis, abnormal 
mobility, crepitation, and displacement being 
readily demonstrated. Palpation of the crest 
of the tibia in the two directions discloses the 
point of fracture, and also any rotation of the 
lower fragment. The exact point of fracture of the 
fibula is sometimes difficult of determination. 
Treatment.-In fracture near the ankle-joint 
the pull of the calf-muscles tends sometimes to 
maintain deformity, and may even demand tenot- 
omy of the Achilles tendon. For the first 3 
weeks 1 posterior and 2 side splints should be 
used, or a fracture-box may be employed. The 
dressings should be removed and the fracture 
inspected and controlled at the end of each week. 
After this time plaster-of-Paris can be employed, 
and the treatment be made ambulatory, as already 
indicated for isolated fracture of the tibia. After 
healing, a painful bony prominence may persist 
on the crest of the tibia, which may require re- 
moval by the chisel. See Knee, Ankle (Fractures). 
LEGITIMACY, LAWS.-The law assumes that 
every child born in wedlock is legitimate unless it 
can be shown that the man and wife had been sepa- 
rated for a longer time than that accepted as the av- 
erage period of gestation, or unless it can be proved 
that the husband was impotent. The accepted 
period of gestation is from 268 to 313 days. A 
child is regarded as legitimate though not conceived 
in wedlock, if the mother afterward marries and 
her condition is recognized by the husband at 
the time of the marriage. 
LEMON (Limon).-The fruit of Citrus limonum, 
official in two forms: (1) Orange, Citrus vulgaris 
and C. aurantium, and (2) Lime, C. acris. The 
rind contains an official volatile oil, and a glucosid. 
The pulp yields about 7 percent of citric acid, 
C6H8O7, which has about the same properties as 
acetic acid, but has much value as a refrigerant 
and antiscorbutic. The expressed juice is largely 
employed as a refrigerant drink in fevers. L., 
01., the volatile oil. Dose, 1 to 5 minims. Tinct. 
Limonis Corticis, a 50 percent tincture, made with 
alcohol. Dose, according to the amount of alcohol 
desired to be given, 1/2 to 4 drams. Acidi Citrici, 
Syr., citric acid, water, tincture of lemon peel, each 
1; syrup to 100. 
LENIGALLOL.-Pryogallol triacetate. A sub- 
stitute for pyrogallol in psoriasis, lupus, etc. 
It is applied in 5 to 10 percent ointment with 
zinc oxid. 
LENSES.-A lens is a transparent refracting 
medium, usually of glass or crystal, which is 
bounded by two curved surfaces or a curved 
surface and a plane surface. 
Lenses may be considered as a juxtaposition of 
prisms with different refracting angles. Convex 
lenses are equivalent to prisms with their bases 
placed together; and concave lenses, to prisms with 
their apices placed together. Therefore, rays 
of light always being deflected toward the base of a 
prism, will be rendered convergent by convex 
lenses, in which the prismatic bases are central; 
and will be rendered divergent by concave lenses, 
in which the prismatic bases are peripheral. 
Spheric lenses are used in ophthalmology in 
6 different forms: 
1. Biconvex, segments of two spheres having 
two convex surfaces. 
2. Planoconvex, the segment of one sphere, 
having a plane surface on one side and a convex 
surface on the reverse side. 
3. Concavoconvex, or converging meniscus. 
4. Biconcave, having two concave surfaces. 
5. Planoconcave, having on one side a plane 
surface and on the reverse side a concave surface. 
6. Convexoconcave, or diverging meniscus. 
Numbers 3 and 6, having opposite sides at differ- 
ent surfaces, are called periscopic or meniscus 
lenses, and are used to avoid spheric aberration 
and to gain a greater field of clear vision. 
The principal axis of a lens is a line passing 
through the optic center at right angles to the sur- 
faces of the lens. Rays passing through this axis 
are not refracted. Rays passing through the optic 
center of a lens, but not passing through the princi- 
pal axis, are slightly deviated, although in practi- 
cal optics they may be considered as straight lines. 
The focal length of a lens is the distance from 
the lens to the point at which parallel rays, 
refracted by the lens, focus. 
LENSES LENSES 
LENSES 
A cylindric lens is a lens with .a plane surface in 
one axis, and a convex or a concave surface in the 
axis at right angles. This form of lens is really a 
segment of a cylinder. Examination of any cylin- 
der-as, for instance, a bottle-will show there is 
curvature only in one direction, from side to side, 
and not in the axis. As the axis of a cylinder has a 
plane surface, the rays are only refracted at right 
angles to the axis, and the strength of the cylinder 
depends on the curvature possessed by the surface 
72 
60 
48 
42 
36 
30 
24 
20 
18 
16 
15 
14 
13 
12 
11 
10 
9 
8 
7 
6i 
6 
5J 
5 
44 
4 
34 
3i 
3 
21 
2i 
21 
2 
No. of the Lens, Old 
System. 
67.9 
56.6 
45.3 
39.6 
34 
28.3 
22.6 
18.8 
17 
15 
14.1 
13.2 
12.2 
11.2 
10.3 
9.4 
8.5 
7.5 
6.6 
6.13 
5.6 
5.2 
4.7 
4.2 
3.8 
3.3 
3.1 
2.8 
2.6 
2.36 
2.1 
1.88 
Focal Distance in 
English inches. 
O 
0 
cc 
1724 
1437 
1150 
1005 
863 
718 
574 
477 
431 
381 
358 
335 
312 
287 
261 
239 
216 
190 
167 
155 
142 
132 
119 
106 
96 
84 
79 
71 
66 
60 
53 
48 
Focal Distance in 
Millimeters. 
H 
M 
K 
0.58 
0.695 
0.87 
0.99 
1.16 
1.39 
1.74 
2.09 
2.31 
2.6 
2.79 
2.98 
3.20 
3.48 
3.82 
4.18 
4.63 
5.25 
5.96 
6.42 
7.0 
7.57 
8.4 
9.4 
10.4 
11.9 
12.7 
14.0 
15.1 
17.7 
18.7 
20.94 
Equivalent in 
Diopters. 
0.25 
0.5 
0.75 
1 
1.25 
1.5 
1.75 
2 
2.25 
2.5 
3 
3.5 
4 
4.5 
5 
5.5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
20 
No. of the Lens, New 
System. 
4000 
2000 
1333 
1000 
800 
666 
571 
500 
444 
400 
333 
286 
250 
222 
200 
182 
166 
143 
125 
111 
100 
91 
83 
77 
71 
67 
62 
59 
55 
50 
Focal Distance in 
Millimeters. 
New 
157.48 
78.74 
52.5 
39.37 
31.5 
26.22 
22.48 
19.69 
17.48 
15.75 
13.17 
11.26 
9.84 
8.74 
7.87 
7.16 
6.54 
5.63 
4.92 
4.37 
3.94 
3.58 
3.27 
3.03 
2.8 
2.64 
2.44 
2.32 
2.17 
1.97 
Focal Distance in 
English inches. 
02 
00 
d 
M 
2 
166.94 
83.46 
55.63 
41.73 
33.39 
27.79 
23.83 
20.87 
18.53 
16.69 
13.9 
11.94 
10.43 
9.26 
8.35 
7.6 
6.93 
5.97 
5.22 
4.63 
4.17 
3.8 
3.46 
3.21 
2.96 
2.8 
2.59 
2.46 
2.29 
2.09 
No. Corresponding 
of the Old System. 
Different Forms of Spheric Lenses. 
1. Biconvex lens. 2. Planoconvex lens. 3. Concavo- 
convex or convergent meniscus. 4. Biconcave. 5. Plano- 
concave. 6. Convexoconcave, or divergent meniscus. 
at right angles to the axis. The axes of the cylin- 
ders in a test case are usually shown by grinding 
and making partially opaque portions of each side 
of the lens in the direction of the axis. 
It must be remembered that a cylinder refracts 
rays of light only in the meridian at right angles 
to its axis, while a spheric lens refracts rays of 
light in every meridian. 
Classification and Numbering of Lenses.-Lenses 
are numbered according to their focal distance, and 
the strength of the lens varies inversely as its focal 
distance. Formerly, lenses were numbered accord- 
ing to the inch system, the unit of which was a 
lens whose focal distance equaled 1 inch-a very 
strong lens. This system necessitated the use 
of large numbers or fractions; and, moreover, the 
denomination inch had different significations in 
different countries, the French inch, for example, 
varying from the English inch. The metric or 
dioptric system of numbering lenses is now in use, 
and the unit is a lens having a focal distance of 
1 meter and is called a lens of 1 diopter strength-a 
comparatively weak lens; a 2-diopter lens is one 
having half the focal length of the 1-diopter lens, 
or 1/2 of a meter. Decimals, of course, are used 
instead of fractions; a lens of a focal length of 4 
meters is called a 0.25-diopter lens. 
Convex lenses form real images, and are called 
positive or plus lenses, and are designated by the 
sign +. 
Concave lenses produce only virtual images, and 
are called negative or minus lenses, and are desig- 
nated by the sign -. 
To convert a prescription written in the old 
system of numbering lenses into the modern met- 
ric system of diopters, we can roughly consider 
the meter as equivalent to 40 inches. A 10-inch 
lens would be equivalent to a lens having a focal 
length of 1/4 of a meter, or 4 diopters. 
The following table from Landolt gives the 
equivalents in both the old and new systems: 
Varieties of Lenses Used to Correct Refractive 
Errors.-1. The simple sphere may be either con- 
vex or concave, and is used to correct the uncom- 
plicated forms of refractive errors. 
2. The simple cylinder is limited in refractive 
power to the direction of its curvature, and is used 
in cases of simple astigmatism in which there is an 
error of refraction in only one meridian of the eye. 
3. The spherocylinder is a combination of a 
sphere with a cylinder, and is used in cases of com- 
pound or mixed astigmatism in which there is 
a different refractive error in the two principal 
meridians of the eye. 
4. The cross-cylinder is a form of lens made up of 
two cylinders with their axes at right angles to 
each other. It is seldom prescribed, but is occa- 
sionally used in making tests. 
For a further description of test-lenses, see 
Refraction. 
Neutralization of Lenses.-The lens is held a few 
inches in front of the eye, and some object, such as 
the vertical and horizontal lines of a window-frame 
or the test-letters, is viewed through it. The lens 
is then moved to the right, and if it is convex, the 
object will move to the left; if it is concave, the 
object will move with the lens to the right. Hav- 
ing determined what sort of a spheric lens we have LENTIGO 
LEPROSY 
under examination, we proceed to neutralize it by 
holding successively a concave lens if convex, or a 
convex lens if concave, until no movement of the 
object is perceived through the lens; therefore, 
to find the strength of a spheric lens, it is only 
necessary to combine it with successive lenses 
of the opposite sign, until one is found which 
neutralizes the apparent movement of objects seen 
through the lens under examination. The more 
rapid the apparent movement, the higher the 
power of the lens required to neutralize. 
Cylindric lenses only show movement in the 
direction opposite to their axes; the movement is 
against in convex cylinders and with in concave 
cylinders. To find the axis, an object presenting 
a straight line, such as the vertical line of the 
window-sash or the edge of a frame, is viewed 
through the lens. As the lens is rotated about the 
visual axis the portion of the vertical line seen 
through the lens will appear to be oblique, as com- 
pared to that seen above and below the lens. This 
LEOPARD'S-BANE-See Arnica. 
LEPROSY.-Lepra vera; elephantiasis Grse- 
corum; black leprosy. 
An endemic, chronic, constitutional disease, 
analogous to syphilis, and varying in its morbid 
manifestations according as the brunt of the disease 
falls on the skin, the nerves, or other tissues. It 
occurs in 3 forms: the tuberculous, the nontuber- 
culous or anesthetic, and the mixed tuberculous. 
The tuberculous or nodular leprosy is attended at 
the onset by debility, depression, dyspepsia, diar- 
rhea, drowsiness, chilliness, and profuse perspira- 
tion, marked vertigo, recurrent epistaxis, fever 
up to 104° F.; after a variable period of days, 
or even months, coming first with edema of the 
eyelids, the leprous spots appear on the face and 
ears, and then on the anterior and external sur- 
faces of the limbs. The exanthem is an erythema, 
varying from a bright-red to a purplish-red or 
mahogany-red tint, associated with the leprous 
oblique displacement takes place in a direction 
contrary to the rotatory motion given a convex 
lens, and in the same direction as the rotatory mo- 
tion given a concave lens. To ascertain the position 
of the axis of a cylinder it is slowly rotated until 
the line seen through it appears continuous above 
and below. If motion from side to side produces 
apparent motion of the object, this line is the 
axis of the cylinder, and if no motion results, the 
line is at right angles to the axis of the cylinder. 
The axis being determined, the cylinder is neu- 
tralized by successive cylinders of opposite cur- 
vature applied in the same axis. 
Spherocylindric lenses are neutralized the same 
way as two cylinders with their axes perpendicular 
to each other. Having neutralized the movement 
in one meridian, we note the result and neutralize 
the movement in the other meridian. 
The phacometer is an instrument designed 
rapidly to discover the strength of lens under 
examination. It is operated by pressing the 
surface of a spheric lens squarely against three 
steel pins, the central one of which is movable. 
When the central one is depressed until all three 
points touch the glass, the curvature of the lens 
is indicated on the dial. 
LENTIGO.-See Freckles. 
LEONTIASIS OSSEA.-See Bone, (Diseases). 
Neutralization of Cylindric Lenses 
deposit of well-defined, shiny, slightly raised 
patches of from one to several inches in diameter. 
Papules then form in crops, gradually reaching 
the size of a hen's egg and of a yellowish to a dark- 
brown color. Tuberculation does not develop 
until from 3 to 6 months after the commencement 
of the disease. Nodules are most common on the 
face, limbs, breast, scrotum, and penis. There is 
also an involvement of the mucous membranes. 
When the disease is fully developed, the face as- 
sumes the characteristic leonine appearance, from 
thickening of the skin. Ulceration eventually 
sets in, and the patient dies of exhaustion or 
complications. 
Nontuberculous leprosy is the most common 
tropical form. The prodromal symptoms are 
marked, and are associated at first with hyper- 
esthesia of the skin. At the end of a year the 
special eruption breaks out, usually on the back, 
shoulders, posterior aspect of the arms, nails, 
thighs, and sometimes in the course of nerves. 
The spots are 1 or 2 inches in diameter, well 
defined, not raised, and of a pale yellow color. 
They spread peripherally, clearing in the center, 
which becomes dry, scaly, and anesthetic. Par- 
alysis is usually a late symptom, and ulceration 
Bacillus Leprae (Extracellular).-{Coplin.) LEPTANDRA 
LEUKEMIA 
is common. Death results from ulceration, 
gangrene, marasmus, or general debility. 
Mixed tuberculous leprosy is the least common 
form, and its symptoms are a combination of those 
of the other two varieties. Destruction of the 
cartilages of the nose and of the soft palate is com- 
mon. 
Etiology.-Leprosy is caused by the invasion of 
the organism by the bacillus leprae. Heredity, 
climate, soil, and mode of living may act as pre- 
disposing causes. 
The contagion is probably chiefly effected 
through direct or mediate inoculation. 
Pathology.-The disease consists of a deposit of 
cells in the corium and subcutaneous tissue, similar 
to those seen in lupus and syphilis. The specific 
bacillus is found in the tubercles, infiltrations, 
lymphatic glands, nerves, etc. 
Diagnosis.-Advanced cases of leprosy are 
easily recognized. The disease may be confounded 
with syphilis, morphea, vitiligo, and lupus. The 
occurrence of anesthesia and the history and course 
of the disease will usually enable one to make 
the diagnosis. In doubtful cases the microscope 
should be resorted to, with the view of discovering 
the bacilli in the affected tissues. The Wasser- 
inann reaction seems as successful in leprosy as in 
syphilis. 
Prognosis.-Always unfavorable. The disease 
progresses, with rare exceptions, to a fatal termi- 
nation. The course is more rapid in the tuber- 
cular than in the anesthetic form. 
Treatment.-Nutritious food, good hygiene, 
and removal to a healthful climate are important 
therapeutic measures. 
The remedies which have proved most valuable 
in the treatment of leprosy are chaulmoogra 
oil (best in the form of antileprol, it is claimed) 
and gurjun oil, used both internally and exter- 
nally in the tubercular variety, and strychnin in 
large doses in the anesthetic form. Nastin and 
eucalyptus are advised. X-ray treatment has 
apparently resulted in cures. 
LEPTANDRA (Culver's-root).-The rhizome 
and rootlets of Leptandra virginica, now called 
Veronica virginica. Its properties are thought 
to be due to a glucosid, leptandrin (dose, 2 to 4 
grains). It is a tonic, laxative, and cholagog, 
and is indicated in indigestion and chronic con- 
stipation. Dose of the extract, 1 to 6 grains; 
of the fluidextract, 10 to 20 minims. 
LEPTOMENINGITIS.-Inflammation of the pia 
and arachnoid of the brain and the spinal cord, 
in contradistinction to pachymeningitis, though 
meningitis alone usually signifies the same as 
leptomeningitis. See Meningitis. 
LEUKANEMIA.-A term applied by von 
Leube to an acute condition of leukemia com- 
bined with severe anemia. It is usually fatal in 
from a few days to three months. The onset 
may be sudden with fever and severe tonsillitis, 
prostration, hemorrhage, extreme pallor and rapid 
decline. There is often general glandular enlarge- 
ment including the liver and spleen. The reduc- 
tion of hemoglobin and erythrocytes with increase 
of lymphocytes (usually the large form) is con- 
spicuous. The red cells may be as low as 1,500,- 
000. The color index is high. 
LEUKEMIA (Leukocythemia).-A chronic dis- 
ease of the blood-making organs, characterized 
by great and persistent increase of the white 
blood-corpuscles; by a diminished number of red 
cells, which are altered in shape and size, and dis- 
play nucleated and degenerate forms; by a les- 
sened amount of hemoglobin; and by enlarge- 
ment of the spleen, lymphatic glands, or medulla 
of bone (Musser). 
Etiology.-The disease may occur at any 
period of life, but is seen mostly in adult males. 
Syphilis, splenic traumatism, pregnancy, heredity, 
malaria, bad hygiene, and repeated hemorrhages 
may act as predisposing causes. It has been held 
to be due to the absorption of toxic substances 
from the digestive tract. It seems probable that 
it is of infectious origin. 
Pathology.-There may be great emaciation. 
The spleen is usually enlarged. The cervical, in- 
guinal, and axillary glands may be the first to en- 
large. The liver may be enormously enlarged. 
There is extensive hyperplasia of the lymphatic 
tissues and reversion of the bone-marrow to the 
embryonal type. 
Symptoms and Course.-By examining the 
blood we detect 2 varieties of leukemia: (1) 
Splenic myelogenous leukemia; (2) lymphatic 
leukemia. Mixed splenic and medullary leuke- 
mias are the most common-called splenomed- 
ullary (lienomedullary) or lienomyelogenic. 
Splenic Myelogenous Leukemia.-The colorless 
corpuscles are greatly increased, but there may be 
only a small diminution in the number of the red 
cells, averaging slightly above 3,000,000, with a 
small decrease of the hemoglobin. Nucleated 
red cells are present in abundance. Eosinophiles 
and basophilic leukocytes are markedly increased. 
Characteristic of this form of leukemia is the 
large corpuscle-the myelocyte, a large cell with a 
large, pale blue nucleus, and not ameboid. The 
great number of these myelocytes present is diag- 
nostic of this form of leukemia. With the decided 
increase in the number of these myelocytes there 
is a corresponding diminution in the lymphocytes 
(youngest leukocytes). 
Lymphatic Leukemia.-This is characterized by 
enlargement of the lymphatic glands and an abso- 
lute lymphocytosis. ■ In this form (about 15 per- 
cent of all cases) there is a greater reduction in the 
number of red cells than in the splenic myelogenous 
form, but there is almost an absence of the nu- 
cleated red cells, in contrast with the splenic variety 
of leukemia. With this reduction of the red cells 
there is a greatly increased number of the leuko- 
cytes (though less so than in the splenomyelogen- 
ous form) especially the lymphocytes, which may 
constitute 90 percent of the white corpuscles. 
These lymphocytes are of all sizes. 
The leading characteristics of leukemic blood are : 
Splenomedullary 
leukemia 
1. Red cells reduced to greater or less de- 
gree (at times below 1,000,000), numer- 
ous nucleated forms. 
2. White cells about 400,000, of which- 
3. Myelocytes form about 35 percent. LEUKOCYTE EXTRACT 
1. Red cells about 3,000,000 or lower, nu- 
cleated forms rare. 
2 White cells 100,000 or lower, of which- 
3. Lymphocytes form 90 percent, either 
large or small predominating. 
4. Myelocytes and eosinophiles very scanty. 
adenin, carnin, gerontin, guanin, heteroxanthin, 
hypoxanthin, paraxanthin, pseudoxanthin, sper- 
min, and the creatinin group, in which are classed 
creatin, creatinin, amphicreatinin, crusocreatinin, 
xanthocreatinin, and some unnamed bases. 
LEUKOPENIA (Hypoleukocytosis).-See Blood. 
LEUKOPLAKIA.-See Tongue. 
LEUKORRHEA.-A whitish mucopurulent dis- 
charge from the female genital canal, popularly 
called "the whites." See Cervix (Diseases), 
Gonorrhea, Vaginitis, Vulva. 
LICE.-See Pediculosis. 
LICHEN RUBER.-An inflammatory disease 
characterized by the appearance of small, flat, an- 
gular, and shining or discrete, acuminated and 
scaly, reddish papules, running a chronic course 
and attended by more or less itching. 
Symptoms.-There are 2 varieties: Lichen ruber 
acuminatus and lichen ruber planus. Some 
authors regard these forms as distinct diseases. 
Lichen Ruber Acuminatus (Lichen Ruber).- 
This is a very rare disease, particularly in America. 
It is characterized by discrete, millet-seed sized, 
acuminated, scaly, reddish papules, which are 
disseminated over the trunk with no disposition to 
grouping. After a duration of years the skin may 
become diffusely infiltrated, reddened, and scaly. 
There is mild or severe itching present. The dis- 
ease is extremely chronic, usually compromising 
the general health, and tending ultimately to a 
fatal termination. 
Lichen Ruber Planus (Lichen Planus).-Lichen 
planus is not an uncommon disease. It may 
develop gradually or rapidly, appearing as pin- 
head-sized to pea-sized flat, quadrangular, or 
polygonal, shining, slightly umbilicated papules of 
a violaceous or reddish color. The lesions may be 
disseminated, but are more commonly closely 
aggregated in patches, which assume frequently 
a linear form. The surface of the papule is at first 
glazed or shining, later covered with fine whitish 
scales. The favorite regions are the flexor surfaces 
of the forearm and wrist and the dorsal surfaces of 
the feet. When occurring upon the legs, the papules 
are apt to become confluent, with the formation of 
elevated plaques of a purplish color. A brownish 
pigmentation often persists after the disappearance 
of the lesions. 
Itching is, in the majority of cases, a prominent 
symptom. The general health remains unaffected. 
Etiology.-The disease is of neurotic origin. The 
most common cause is nervous exhaustion result- 
ing from worry, overwork, etc. It is most fre- 
quently observed in middle-aged individuals. 
Pathology.-The pathologic process in the plane 
variety consists of a dilatation of the papillary 
blood-vessels, a dense, sharply circumscribed 
round-cell infiltration in the upper part of the 
corium, proliferation of the cells of the rete muco- 
sum, with either flattening or elongation of the 
papillae. The papules are claimed by some to 
develop at the sites of hair follicles; by others, 
around the sweatducts. 
Diagnosis.-The characteristic features of the 
papules of lichen planus are their angularity, 
flatness, shining surface, violaceous color, and 
LICHEN RUBER 
Lymphatic 
leukemia. 
Symptoms.-At first the symptoms are those 
of the other anemias: Insidious onset, pallor, faint- 
ness, vertigo, dyspnea, weakness, anorexia, indi- 
gestion, headache, palpitation. Hemorrhages 
are common. Enlargement of the spleen or lym- 
phatic glands or both are found. There may be 
moderate fever. The enlarged glands are free 
from active inflammation and give rise to pressure 
symptoms. There is a tendency to serous effu- 
sions in the later stages and emaciation appears. 
The pulse is rapid and easily compressible. Nausea 
and vomiting are common. The urine usually 
contains an increased amount of uric acid. 
Diagnosis can only be made by the blood examin- 
ation. See Blood, Diagnosis of Leukemia. 
Prognosis is usually unfavorable. The lymphatic 
form may be fatal in from 6 weeks to 2 months. 
Treatment.-The best hygienic surroundings 
possible should be given the patient, and good, 
nutritious food supplied. The patient should never 
exhaust himself by too active exercise. If there is 
a history of malaria, quinin in 3- or 4-grain doses 
should be given 3 times daily. Arsenic is highly 
recommended, and any prescription recommended 
for pernicious anemia may be given. Benefit has 
been derived, it is claimed, from X-ray treatment 
by the Pancoast method (exposure consecutively 
of the various bone-marrow regions of the body). 
In the splenomyelogenous type remarkable re- 
sults have been obtained from the use of the X- 
rays. Some improvement is reported in cases of 
the myeloid type from the use of mixed toxins of 
streptococcus and B. prodigiosus. See Anemia 
(Pernicious); Blood (Examination). 
LEUKOCYTE EXTRACT.-According to Hiss, 
an aqueous extract of washed leukocytes, obtained 
from healthy rabbits after an injection of aleuro- 
nat into the pleural cavity, has a curative action 
when injected in infectious diseases. Satisfactory 
results have been obtained in pneumonia, furun- 
culosis, erysipelas-and cerebrospinal meningitis. 
LEUKOCYTOSIS.-See Blood (Examination). 
LEUKODERMA.-Leukasmus; achroma cutis; 
leukopathy. A congenital pigment anomaly of 
the skin, in which, at the time of birth or soon after, 
whitish patches or bands, irregularly outlined and 
usually isolated, appear upon the skin of the child. 
See Vitiligo. 
LEUKOMA.-An opacity of the cornea the re- 
sult of an ulcer, wound, or inflammation, and pre- 
senting an appearance of ground glass. See 
Cornea. 
LEUKOMAIN.-The name applied by Gautier 
to the nitrogenous bases or alkaloids necessarily 
and normally developed by the vital functions or 
metabolic activity of living organisms, as distin- 
guished from the alkaloids developed in dead 
bodies, and called by Selmi ptomains. See 
Ptomain, Autointoxication. From their chemic 
affinities leukomains may be divided into two 
groups: The xanthin group, comprising xanthin, LICORICE 
LIFE ASSURANCE EXAMINATION 
umbilication. These points will differentiate the 
disease from papular eczema, psoriasis, and the 
papular syphilid. The papules of eczema are 
rounded, somewhat acuminate, brighter red in 
color, and have a different history. 
Prognosis.-The prognosis of the acuminate 
variety is extremely guarded; of the plane variety, 
favorable. 
Treatment.-The treatment is both general and 
local. Attention to diet and hygiene should not be 
neglected. Cod-liver oil, iron, strychnin, etc., 
are often indicated. Arsenic is by far the most 
valuable remedy, exerting almost a specific in- 
fluence upon the disease. In some cases, particu- 
larly when arsenic fails, mercury acts most favor- 
ably. 
Locally, applications containing tar, phenol, 
menthol, salicylic acid, mercury, etc., are to be 
employed. The following formula, suggested by 
Unna, has been successfully used: 
I). Carbolic acid, gr. x to xx 
Mercuric chlorid, gr. ij to iv 
Zinc oxid ointment, 5 j. 
Apply twice a day. 
LICORICE.-See Glycyrrhiza. 
LIFE ASSURANCE EXAMINATION. General 
Remarks.-Life assurance is a contract by which 
a corporation agrees to pay a stipulated sum, such 
as may be agreed upon between the parties, either 
on the death of the life assured or within a limited 
number of years, as the case may be, provided the 
applicant fulfils his part of the contract. The 
latter consists in the regular payment of fixed 
sums, known as premiums. Before a company 
will enter into such a contract it usually requires 
the recommendation of at least two medical 
officers of the company-the one the local exam- 
iner, to whom the applicant submits for medical 
examination as to his present state of health, 
and to whom also he must furnish a truthful 
report of his past ailments, as well as data with 
regard to his family history; the other, the medical 
director, or chief medical officer, whose duty it is 
to examine carefully this report and advise the 
company as to the desirability of accepting the 
risk. 
Of late years the amount of money involved in 
these contracts has reached enormous dimensions. 
The financial standing and the success of all 
companies depend to so large an extent on the 
judicious report as to the past and present state 
of health of the applicant, as well also as the moral 
hazard of the risk, that it is necessary that the 
medical inspection and supervision of each in- 
dividual risk should be made with great care. 
The first important point it is desirable for the 
medical examiner to remember is that all assurance 
companies base their premiums on the assumption 
that their assured lives shall be healthy individuals 
of healthy families :t. e., not only must the applicant 
for assurance be himself free from disease and of 
good habits, but he must also belong to a family 
of healthy brothers and sisters (if he has any), 
children of healthy parents. 
With such a history, the average duration of 
life at all ages has been estimated by actuaries 
of several companies, who have varied but a few 
months as to its duration at the different ages; 
that is to say, as to the number of years longer 
which a healthy person, as above stated, of a 
certain age, is expected to live. This is what they 
call their "expectation." The rates of assurance 
for first-class lives are fixed accordingly. See 
Life (Expectation). 
The "selection" of the risk is the duty of the 
medical board, which may consist of one or more 
"medical directors," so called because they direct 
the medical affairs of the company. Most 
English companies have but one such officer, 
whom they call the "medical referee" or "chief 
medical officer." 
It is the duty of these officers to examine the 
medical reports of all examinations and to elimi- 
nate the objectionable risks. Many cases are re- 
jected by medical directors because of features 
which their greater experience leads them to 
believe are hazardous, although recommended 
as first class by medical examiners. 
In other cases, although they may consider the 
risk not a safe one on a cheap plan, they may 
think it assurable on some plan with large annual 
payments, and offer a policy on an endowment 
plan or some plan more favorable to the company 
than the one applied for. If the applicant will 
not accept this policy, the risk will be completely 
declined and placed on the black-list. 
The medical examiner who has examined the 
applicant may consider him an unobjection- 
able risk because at the time of examination he is 
perfectly healthy, but the medical director, in 
reviewing the whole history of the case and acting 
upon the statistics furnished by the actuarial 
department, as well as his own observation in ex- 
amining death claims, may, and very frequently 
does, feel compelled, acting in the interest of the 
company, to reject the risk, notwithstanding the 
favorable recommendation of the examiner. The 
objectionable features in the case may have been 
only an incomplete family history and light weight 
compared with height. 
The decision of the medical board may or may 
not be referred to the executive, or board of direc- 
tors (not medical). They nearly always follow the 
recommendation of the medical board, but, of 
course, may do otherwise, if they so decide. To 
be binding, the policy must have the signature of 
the executive. 
All appointments of medical examiners are made 
by the medical board or medical director. Some 
companies have a "medical referee," to whom all 
applications for appointment as examiner are sent. 
With some companies the medical referee acts as 
medical inspector, whose duty it is to visit the 
various agencies and acquire information as to 
the standing of the various medical examiners. 
He also occasionally is called upon to investigate 
the circumstances connected with death claims in 
the previous history of which there may be some 
unsatisfactory points to be explained. 
No applicant who at the time of examination LIFE ASSURANCE EXAMINATION 
LIFE ASSURANCE EXAMINATION 
is suffering from disease in any form should be 
accepted at that time. Many, also, who are quite 
free from present disease must be considered bad 
or impaired risks. These, however, are usually 
insurable, but at rates and on plans varying with 
the nature of the impairment. With some this 
impairment is likely to diminish as they grow 
older, while with others the contrary is the case; 
hence we have those who may be classed as lives 
with "diminishing risks," and also lives with 
"increasing risks." 
Gout, arteriosclerosis, and consequences-dis- 
eases more frequently found after middle life- 
are examples of the latter class. In the former 
a tendency to tuberculosis, especially of the lungs, 
may be included, inasmuch as the liability lessens 
as the individual grows older. Assurance com- 
panies take different measures to meet these vari- 
ous risks. Some, more especially the British, 
impose in nearly all cases an addition of a certain 
number of years to the age of the applicant, thus 
increasing the amount of premium required. 
Others, particularly American officers, offer the 
applicant an "endowment" policy, on the theory 
that the extra risk is overcome by shortening the 
term of the policy and exacting a correspondingly 
heavier premium. Either of these plans may be 
comparatively safe for cases of "increasing risks," 
but they can hardly be considered as based on 
sound actuarial principles when applied to the case 
of "diminishing risks." 
It is the practice of some companies to place 
a "gradually reducing lien" or "contingent debt" 
on the policy issued on such a life. Both the 
amount of the lien and the duration of its ex- 
istence vary according to the nature of the risk, 
and many authorities consider that this is a more 
correct method of dealing with such cases. 
Duties of Medical Examiner.-The medical 
examiner must always remember that he is the 
official representative of the company, and that 
he acts purely in its interests. Whenever there 
is any doubt as to the advisability of accepting 
the risk as a first-class one, it is his duty to give 
the company the benefit of that doubt. Under no 
circumstances should he allow himself to be 
influenced, either by agent or applicant, in sup- 
pressing any information in regard to family or 
personal history. Illness of any kind for which 
the applicant may have consulted a physician, 
especially if within the last few years, should be 
fully reported on, both as to its nature, the length 
of the confinement to bed and to the house, and 
any other information of importance in connection 
with it. Before a policy will be issued the medical 
board must have full particulars of the past 
medical history of the applicant, to enable 
them to form an opinion of the value of the risk, 
quite independent of the medical examiner's views. 
It may not always be advisable for the medical ex- 
aminer to put in writing on a printed form his 
opinion, especially as to habits, if they are ob- 
jectionable. They will be sure to be read over 
by the agent, and probably related to applicant. 
This difficulty can be readily overcome by the 
medical examiner writing a confidential letter 
to the medical director giving more complete in- 
formation as to any unfavorable point in either 
personal or family history. 
In proceeding to examine the applicant the 
medical examiner should remember that he must 
do so with as much care as he would were it an 
ordinary office connection on the applicant's 
behalf, according to the printed form of the com- 
pany. There are a number of questions he is 
expected to ask, both with regard to the family and 
also the personal history. The replies to these 
questions he must write down. Now, for this 
purpose it is advisable to have the applicant so 
placed in front of the light that, while getting the 
replies to the various questions, he may study his 
appearance, and thus form a general idea as to his 
age, general health, and prospects of longevity. A 
good rule is to commence these questions by asking 
the applicant if he has ever been refused by any 
company, and also if every company to whom he 
has applied has issued a policy on the plan applied 
for. The reason of this is that it is almost of 
daily occurrence in companies doing a large busi- 
ness to find that as soon as the agent who has can- 
vassed the risk has the slightest hint that the appli- 
cant is not a first-class life, and probably because 
of conscientiously believing the examiner to have 
been unnecessarily strict, he will at once take the 
man to another company in the hope that its 
medical representative may not be so particular. 
Unfortunately, it often happens that through a 
hasty and incomplete examination the second 
doctor may overlook a slight heart murmur or 
some other feature recognized by the first examiner, 
and advise issuing a policy, with the consequence 
that his own services may, quite possibly, be dis- 
pensed with. This happens in this way: So soon 
as a risk is declined, notice of this refusal is 
sent to a central bureau, and from there a printed 
card is posted to all the companies who are mem- 
bers of the "exchange." The cards thus received 
are kept on file in cabinets. Before a policy can 
issue from the office every name that has been 
recommended for assurance is searched for in these 
cabinets, and if found in this black-list, informa- 
tion is obtained as to the reason why the previous 
company did not issue its policy. In this way 
many a fraud on the part of the applicant (who 
has denied previous refusal) and many an error 
on the part of the physician have been discovered. 
At the same time it must be remembered that 
the denial by the applicant of his refusal by an- 
other assurance company does not always mean 
fraud. He may be, and very often is, in ignorance 
of the reasons of the policy not having been issued. 
In making this examination there are four dis- 
tinct points which should carefully be inquired 
into by the medical examiner and reported upon: 
1. Family history. 
2. Past medical history. 
3. Past and present habits. 
4. Present state of health as indicated by medi- 
cal examination. 
In reporting upon all the above the medical 
examiner must not lose sight of the fact, already 
referred to, that he is examining in the interest of LIFE ASSURANCE EXAMINATION 
LIFE ASSURANCE EXAMINATION 
the company he represents. With that in view, 
he should be on his guard as to the possibility of 
the applicant concealing information connected 
with family or personal history which might in- 
fluence the decision of the company as to issuing 
a policy. That concealment may be intentional 
or otherwise. Should a death claim arise within 
3 or 4 years, notwithstanding the false statements 
made, the company is barred by the laws of many 
states from making this a point in the defense, 
unless it can be proved that this statement was 
fraudulently made and had a direct bearing on 
the cause of death. Nowadays most companies 
voluntarily adopt a limited period (generally 
2 or 3 years) after which time the policy is 
absolutely indisputable, notwithstanding any 
misstatements. 
Family History.-Taking up, now, the first of the 
headings above referred to-the family history- 
the replies to the questions as written down by the 
medical examiner are very frequently the cause of 
much inconvenience and delay in issuing a policy. 
In the case of death of either parent or other mem- 
ber of the family, the terms "general debility," 
"anemia," "la grippe," "burst a blood-vessel," 
"hemorrhage," or, in the case of sisters or mother, 
the terms "change of life" or "childbirth," are 
often used without any explanatory notes as to 
the duration of illness or presence or absence of 
cough. The experience of all medical directors 
shows that these terms are frequently made use of 
when the actual cause of death has been tuber- 
culosis of the lungs. Many an applicant quite 
conscientiously gives "childbirth" as cause of 
death of mother or sister, believing it to have been 
the direct existing cause of the diseased condition, 
which may have terminated in death a few months 
after delivery. In view of this tendency on the 
part of the public in the absence of such definite 
information as will satisfy the medical director that 
tubercular disease may be completely eliminated, 
he will not be justified in treating the case as an 
unimpaired life, unless, indeed, there are other 
features of a personal character, which in his 
opinion may offset these unfavorable points. 
The mortality from tuberculosis is so great that 
when indefinite statements are made regarding 
family history, suspicion is naturally directed that 
way. Hence the absolute necessity arises of the 
medical examiner furnishing such complete and 
detailed information as will enable the medical 
director to form an accurate opinion as to the facts 
of each case. 
Other indefinite terms are occasionally made use 
of by inexperienced medical examiners, such as 
"dropsy" (a mere symptom of a diseased condi- 
tion of some organ, such as heart, kidney, or liver), 
"heart failure," "dissipation," "congestive chill." 
All such cases require full inquiry and explanation. 
When either parent has died of consumption, it 
is particularly desirable that inquiries should be 
made as to the cause of death (if any deaths) of 
other members of deceased's family, so as to be 
able to eliminate any chronic lung trouble, for, 
indeed, in an insurance point of view, the company 
should take the benefit of any doubt that may exist, 
and assume that every suspicious case is one of 
tuberculosis. 
Seeing that consumption accounts for the largest 
number of death claims in the mortuary list of all 
assurance companies, it is one which, naturally, 
the medical department tries most to guard 
against. There is little doubt that some of these 
claims are avoidable. With our more modern 
views of the nature of the disease, and its manner 
of transmission, the question of heredity loses some 
importance. Although an important factor, the 
environment, occupation, and physique of the 
applicant are of even greater importance. As a 
rule, however, the progeny of strong and healthy 
parents possess more endurance, and are less 
susceptible to contagious diseases, other things 
being equal, than those of feeble parents. There- 
fore, when exposed to the contagion, the latter are 
less liable to resist the attack of the bacilli. 
It is a debatable question in the case of either 
parent dying of consumption at an age when the 
children are very young, whether such a risk 
should be considered more or less hazardous on the 
part of the children subsequently seeking assurance. 
In favor of the latter view may be stated that they 
are exposed to the contagion at a time-early 
childhood-when the individual has great re- 
sisting powers to that disease. Later on, when 
developing into men and women, the danger of 
contracting the disease is greater should they be 
exposed to the contagion. On the other hand, it 
should not be lost sight of that if either parent died 
within a very short period of the birth of the child 
seeking assurance, there is a probability of that 
child inheriting, to some extent at least, the im- 
paired vitality of the parent. 
Living in the same house, especially sleeping in 
one, in which an individual has recently died from 
consumption, or is suffering from it, neutralizes to 
a certain extent the favorable importance of a 
first-class personal physique, and even of over 
average weight. This is especially the case in 
regard to man and wife, so that with young 
married men the fact of the wife suffering from the 
disease or from any chronic lung trouble which 
would give reason for suspecting consumption, 
seriously impairs the life of the husband, so far as 
assurance is concerned. 
Arteriosclerosis and its resultant affections of the 
system, such as some forms of kidney-disease, 
apoplexy, and the like, if the cause of 2 or more 
deaths in a family, should be considered as placing 
an applicant in the under average class, especially 
if associated with even a moderately free use of 
alcohol. Many of these causes are really the result 
of a "gouty" condition, and if death of either 
parent can be assigned to that cause, the risk is 
rendered more hazardous, as we have unfortu- 
nately many evidences of its hereditary nature. 
When such a family history is present, it is the 
duty of the medical examiner to inquire minutely 
into the personal history of the applicant for any 
evidences of a similar condition, such as frequently 
occurring attacks of tonsillitis, bronchitis, and 
eczema. These remarks apply more to individuals 
over 45 years of age, and with almost equal em- LIFE ASSURANCE EXAMINATION 
LIFE ASSURANCE EXAMINATION 
phasis in a family and personal history of rheu- 
matism. 
Past Medical History of the Applicant.-Natur- 
ally, this has an important bearing on the desira- 
bility of the company assuming the risk. Again, 
we think of the dreaded disease consumption, and 
cannot help observing in private and hospital 
practice that the frequent occurrence of catarrhal 
conditions in an individual who is the offspring of 
tubercular parents makes him a particularly 
hazardous risk, although at time of examination 
he may appear to be perfectly sound. 
No less important is the history of the occurrence 
of pleurisy within recent years. The examiner 
should be most careful in making the examination. 
He may be able to locate where the pleuritic con- 
dition existed, but if the history of the case pointed 
to the probability of its being toward the apex of 
the lung and of recent date, the risk should be con- 
sidered an impaired life. If a history of tuberculo- 
sis is present in the family, and the applicant is 
below the average weight, the risk should not be 
accepted at ordinary rates. A death in the 
family from pleurisy should be looked upon with 
suspicion as possibly being associated with tuber- 
culosis. 
The view too often entertained that a history of 
pleurisy in an applicant is of very little conse- 
quence is a grievous error. In recorded cases in 
which death has. occurred from this disease and 
postmortem examinations have been made, nearly 
50 percent have been tuberculous. Of those who 
have recovered from the attack almost one-fourth 
subsequently developed tuberculous disease of the 
lungs. In cases in which the disease has lasted any 
length of time fully 50 percent die of tuberculosis. 
Hemoptysis, if within recent years, should cer- 
tainly be considered sufficient grounds for re- 
fusing a risk. There are good reasons for believing 
that it may occur without tuberculous disease, but 
the cases of that kind are so very rare that for 
assurance views it is safe to look upon all such as 
tubercular. If an applicant has been in perfect 
health since the attack, and has increased in weight 
so that he is above the average weight for his 
height, and an interval of 8 or 10 years has elapsed 
since the hemoptysis, the risk may be considered 
fairly safe, but he cannot be a first-class life. • He 
is safely assurable on some plan, such as an en- 
dowment, or with a small lien placed on the policy. 
Cancer is a disease about which there appears to 
be but little unanimity in practice among com- 
panies with regard to the acceptance of those 
risks. There can be little doubt that the relative 
number of deaths from cancer is greater now than 
it was many years ago. This can, however, be 
readily accounted for by the fact that the mor- 
tality of the younger ages is very much less than 
formerly-that is to say, that more individuals 
survive to the ages at which cancer makes its 
appearance. The practice of some companies in 
disregarding a single death from cancer in the 
family history seems to be justified by mortality 
lists. Two or more deaths in the family from any 
cancerous affections are, however, sufficient to 
cause a life to be treated as impaired. 
Diseases of the Genitourinary Tract.-An appli- 
cant suffering from an attack of gonorrhea should be 
put off until some time after the disease has been 
fully cured. It may result in a stricture which in 
late years (through secondary diseased conditions) 
may endanger life. Stricture, if obstinate and not 
readily and quickly yielding to treatment, may 
cause secondary diseased conditions, such as 
pyelitis or disease of the bladder or kidneys of a 
more chronic form. Such troubles may arise from 
an apparently insignificant stricture. Such an 
applicant should not be considered first class. 
Some years should be taken off his "expectation" 
and the premium increased accordingly, or a 
policy on a short term endowment only granted. 
Syphilis.-That individuals may die of syphilis 
can be easily proved by referring to the pathologic 
museum of any hospital or school of medicine, and 
that many of them may die at periods remote from 
the primary inoculation, clinical history will attest. 
For these reasons a man who has had syphilis, al- 
though reported cured, cannot be considered a 
"selected" life. The practice of assurance com- 
panies varies with regard to such lives. Many com- 
panies will issue any form of policy provided a cer- 
tain time, say 3 years, has elapsed since final dis- 
appearance of symptoms, more especially if they 
have had several months' treatment. Others again 
will issue only a limited policy, say 20-year endow- 
ment, without any extra premium. When an 
applicant has had syphilis and has undergone a 
regular course of medical treatment for say 3 
years, and the individual has a healthy appearance 
and leads a regular life, and if at all uses alcohol 
only very moderately, the risk is considered by 
many companies as presenting no objections to 
being first class. Other companies again will de- 
mand an extra premium corresponding to that 
caused by the addition of 6 or 7 years to the age 
of the applicant. Still others again impose a lien 
running off in 15 or 20 years. 
It must not be overlooked that many, even of 
the so-called cured, patients, may die 15 or 20 years 
after the infection from some such disease or 
locomotor ataxia or some affection of the brain, 
while others succumb at earlier periods from 
syphilitic affection of the lungs, kidneys, liver, etc. 
Albuminuria is a condition regarding which there 
appears to be an utter absence of unanimity of 
action on the part of the medical boards of the 
various companies. All medical authorities are 
fully agreed that the presence of albuminuria in a 
young person is not incompatible with perfect 
health. 
Many individuals in whom albuminuria is pres- 
ent, and who were declined for assurance-some 
as far back as 27 years ago-have during that 
time enjoyed the best of health. On the other 
hand, cases are so numerous in which the detection 
of albuminuria has been followed by so limited a 
term of existence, even in the young, that its 
presence at the time of examination should be 
sufficient to postpone the acceptance of the risk 
until such time as it can be reported that frequent 
examinations within some definite time have 
proved the absence of albumin. LIFE ASSURANCE EXAMINATION 
LIFE ASSURANCE EXAMINATION 
Should an examiner meet with such cases, he 
should make a most careful examination of the 
heart-sounds, especially in the aortic region, so as 
to be able to include that very important indication 
of arterial changes, the accentuated second sound, 
and report in full all the facts. 
Otorrhea is a condition which should be in- 
quired into if present. It may be of little conse- 
quence, but as many of those in whom this con- 
dition is present die from the extension of the 
disease, as a result of septic infection or of inflam- 
matory affection of the brain or its membranes, 
the life cannot be considered otherwise than as 
impaired. By the term otorrhea we understand a 
chronic suppurative inflammation of the middle 
ear. It is frequently a sequence of either measles 
or scarlet fever, but it may follow an acute inflam- 
matory affection, as a result of cold in a person 
with scrofulous tendency. The mastoid cells may 
become involved and place the life of the individual 
in jeopardy. Even in cases in which the discharge 
has ceased for a time a slight existing cause may 
give rise to inflammatory processes which, by 
extension, may cause alarming cerebral symptoms. 
In cases of this kind the examiner should elicit 
from the applicant the duration of the discharge, 
and, if it has now ceased, the time of its disappear- 
ance. He should also endeavor to find out whether 
or not it followed any of the eruptive diseases. All 
these facts should be fully explained in the medical 
report. 
The actual presence of a discharge is not enough 
to cause rejection of the risk. Some companies 
may accept on a short term endowment, while 
others may place a small lien on the policy, running 
off in say 15 years; while others may meet the 
extra risk by charging a higher premium, resulting 
from adding an extra 7 years to the age. 
Inflammation of the bowels, in the past history 
of an applicant, is a term about which examiners 
are very often not sufficiently accurate in their 
reports. When given as one of the ailments for 
which he has had medical care, the date of the 
occurrence and duration of illness should be fully 
reported. The medical examiner should get from 
the applicant a description of symptoms from 
which he suffered, and report accordingly. With- 
out a detailed or satisfactory report the medical 
director will be in duty bound to accept the views 
of most physicians and surgeons, who look upon 
the great majority of such inflammatory cases as 
attacks of appendicitis, which, if recent, are so 
liable to recur. There can be no doubt that often 
when the applicant reports that he has had in- 
flammation of the bowels it may have been only 
some catarrhal trouble, or an attack of enteritis, or 
a mild attack of dysentery. Should there be no 
satisfactory evidence, so far as the report goes, that 
the attack was not appendicitis, and if it occurred 
recently, say within from 3 to 5 years, the medical 
director will probably take the benefit of the doubt, 
and postpone the acceptance of the risk for a 
limited time after its occurrence (3 to 5 years 
generally), or advise issuing a policy only on some 
heavier payment plan, or its equivalent. 
A perfect cure after removal of the appendix 
renders the risk unobjectionable on the ground of 
a previous appendicitis. 
Habits.-The abuse of alcohol in its various 
forms is a source of great trouble to assurance 
companies. In the first place, a very large pro- 
portion of death claims are either directly or in- 
directly due to it. Most physicians agree that its 
very moderate use may cause no injurious effect 
on the health of the individual. All men know 
that its excessive use is decidedly injurious. It is 
an extremely difficult matter to decide as to the 
dividing line between the two conditions. It can 
be safely assumed that the man who uses over, say, 
2 or 3 ounces of spirit or its equivalent a day, is 
producing injurious structural changes in . his 
vascular system. But few individuals admit the 
full quantity taken daily. The facts tend to prove 
that the offspring of neurotic parents, when users 
of alcohol, are more prone to its excessive use. In 
estimating, on this ground, the value of a life 
seeking assurance, heredity should be considered. 
One who uses alcohol freely in any form, either of 
whose parents were addicted to its use, must be 
considered a very hazardous risk. 
When any doubt exists, the company should un- 
questionably take the benefit of that doubt either 
by not assuming the risk or by issuing a policy on 
some short term plan, with heavy payments, such 
as a 10-year or 15-year endowment, or, again, by 
adding 7 or 10 years to the age with correspond- 
ingly increased premium. 
Medical Examination of the Applicant.-By the 
time the medical examiner has completed his 
questions and noted down the replies thereto, he 
will have formed a fair idea of the nature of the 
risk his company is asked to assume. He will 
have observed the man's general appearance- 
whether anemic or plethoric-by the general 
appearance of face and ears, as well as the char- 
acter of his breathing, whether or not there is a 
probable tendency to tubercular disease. At the 
same time he will have given the applicant a 
chance to overcome that nervousness so often met 
with in applicants for assurance, when knowing 
they have to undergo medical inspection. When 
possible, in fact in all cases, the chest should be 
uncovered so that an inspection, as well as a 
proper stethoscopic examination, may be made. 
Very often the inspection will reveal the scars of 
croton oil, which tell a tale of previous lung 
trouble. Without the naked chest examination it 
is impossible to say whether one-sided subclavicu- 
lar depression is present or not. If present, it 
may indicate a scarred and contracted lung in 
which disease is only temporarily in abeyance, or 
it may point to a permanently collapsed lung as 
the result of an old pleuritic effusion. These con- 
ditions are so often present in those seeking 
assurance, and, when present, so frequently in- 
dicate an impaired life, that it should be strongly 
impressed upon all medical examiners that if they 
omit this necessary inspection of the chest, they are 
neglecting an important duty devolving on them 
as the medical representative of the company. 
Having made the inspection, the examiner 
should proceed to percussion, not omitting the area LIFE ASSURANCE EXAMINATION 
LIFE ASSURANCE EXAMINATION 
of cardiac dulness, having done which he should 
now make the necessary auscultation of the heart 
and lungs and report their condition. When any 
abnormal condition is present, it should be noted. 
In auscultating the heart any such, of course, must 
be stated in the report; in the case of murmurs, 
their locality should be clearly designated, as 
some companies which accept impaired fives, 
while completely declining to accept a case of 
aortic regurgitant murmur, may accept one with 
a mitral murmur on some protecting plan. Any 
murmur, no matter how slight, provided it is con- 
stantly present with each impulse of the heart, 
should be reported. Clinical experience teaches 
us that the gravest disease of the heart may be 
present with only a very soft murmur. There is 
another point of great importance, and one which, 
if carefully examined for, and, when present, re- 
ported upon, would very often save companies 
heavy death claims. This is the accentuation of 
the second sound in the aortic region. It nearly 
always means peripheral vascular changes. It is 
particularly to be dreaded when there is a family 
history of apoplexy or kidney-disease, as there are 
grounds for suspecting the probability of heredi- 
tary tendency to the same vascular changes that 
may have caused these deaths. Clinical experience 
certainly supports that belief. The occupation of 
the applicant, if one in which there is continuous 
mental strain or vascular excitement, may be con- 
sidered as a very important factor in that same de- 
generative change. It is an interesting fact that 
in the experience of many large companies cerebral 
affections are responsible for a greater percentage 
of mortality among those who are able financially, 
and who assure for amounts above $5000, while 
diseases of the respiratory system cause more death 
claims among tfyose who assure for smaller amounts. 
The weight is of great importance from a life 
assurance point of view. The applicant should, if 
possible, be weighed at the time of examination. 
All above maximum or below minimum weight 
for their height (with certain exceptions) are con- 
sidered impaired risks. The exceptions would be 
when diminished or excessive weight is a family 
characteristic, associated with longevity. Thus, 
if the applicant is considerably above the average 
weight, and one or more brothers or sisters are the 
same, and either parent is alive in advanced 
years, and of the same physique, these character- 
istics would considerably modify the bad qualities 
due to weight. With a slight history of tuberculo- 
is in the family, an applicant considerably above 
average weight, and quite healthy otherwise, the 
risk might be considered a fair one. 
A large American life assurance company made 
a special investigation into the mortality among 
its members who were considerably over the aver- 
age weight at the time of assurance. Those whose 
parents were stated in the application to be still 
living, or, if dead, to have died at over 70 years of 
age, showed an excellent mortality record; while 
those either of whose parents had died before 70, 
showed a very heavy death-rate. 
Diabetes, when known to be present, is certainly 
a bar to assurance. It is quite possible for an in- 
dividual to have glycosuria of a temporary char- 
acter, due probably to some gouty condition in 
an individual with a tendency to obesity. Such 
a state may be present without the more serious 
symptoms of diabetes, and when cured after an 
interval of time, the individual may be assurable 
as an impaired risk with extra premium. During 
this interval the urine should be examined several 
times, with a report of such a character as to show 
that the condition could only have been a tem- 
porary one, and that it has been perfectly normal 
for many months. The persistent or repeated 
presence of sugar, or the necessity for an anti- 
diabetic diet should disqualify for assurance on 
any terms. 
Women in Life Assurance.-A very important 
point to remember in considering women in life 
assurance is the fact that the mortality among 
assured women is much greater than among those 
who are uninsured-the latter compare very 
favorably with men. There must be some reason 
for the unfavorable comparison. It may be 
accounted for by the fact that many of the cases 
are of a purely speculative character. A large pro- 
portion of the assured are married women, who 
have not been in very good health, and are easily 
persuaded by their husbands to apply for policies. 
Naturally, the medical examiner does not like to 
subject them to the same scrutinizing examination 
that he should in the case of men. By his omis- 
sion to do so a soft cardiac murmur or incipient 
tubercular disease of the lungs may readily escape 
observation, or, again, a woman approaching the 
menopause may attach no importance to indica- 
tions of commencing uterine disease, and report 
herself as being quite healthy, in reply to the usual 
questions. It is advisable, when examining 
married women and writing down the replies to 
questions, to inquire if the husband is assured. 
Should such not be the case, the interrogatories 
should be more searching, in order to ascertain if 
she is concealing information regarding previous 
consultations with medical men, or any other 
matters with respect to her health about which she 
may be uneasy. 
If assurance were as common among women as 
it is among men, there can be little doubt they 
would prove more profitable risks for the compan- 
ies. According to statistics, fewer females die 
annually than males; the average duration of life 
is slightly longer. It is quite true the mortality 
from phthisis is greater among them than in males; 
more also die from cancer; and to both these fre- 
quent causes of death must be added the risk of 
childbirth. Now that outdoor sports, such as 
bicycling, golf, etc., are becoming more general, 
sunshine and fresh air are already helping to 
diminish the relative mortality from tuberculosis 
among women, while among men death from 
accident and alcoholism are on the increase. 
Identification.-Fraud in many ways is continu- 
ally being attempted on companies. False state- 
ments of all kinds, as well as suppression of im- 
portant facts in family as well as in personal his- 
tory, are of daily occurrence. Unfortunately, 
fraud of a more criminal character, such as im- LIFE ASSURANCE EXAMINATION 
LIGATURE 
personation, is not infrequent. A healthy indi- 
vidual of similar physique to one suffering from 
some fatal disease may present himself for exami- 
nation and be favorably reported upon. Height, 
color of eyes and hair, as well as a description of 
marks, such as moles or deformities, may to some 
extent avoid some of these. 
It is also advisable in every case to have the 
applicant sign his name at the time of examina- 
tion, and in presence of the medical examiner, this 
signature being altogether independent of that in 
application for assurance. 
Tropical Risks.-Recent arrivals in tropical 
climates are much more hazardous risks than those 
who have been living there for several years; so 
also are young lives more hazardous than their 
seniors. A healthy man of over 30, leaving a 
temperate climate for a hot one, is not so hazardous 
a risk as one say between 18 and 25; the latter is 
much more liable to die from dysentery, malaria, 
etc. Extra rates should be charged, varying with 
the age of the individual and its corresponding 
extra risk. 
Among the many occupations that tend to 
shorten life we must include those who are engaged 
actively in stock-exchange transactions. The 
constant excitement and continuous mental strain 
and worry has an injurious effect, often shown by 
changes in the vascular system and their secondary 
effects either in brain or kidneys. 
LIFE, EXPECTATION.-The average number 
of years a person is expected to live, as calcu- 
lated from life-tables. Below is the "Actuaries' 
or Combined Experience Table of Mortality" as 
given by Greene. 
LIGATURE.-A cord or thread of any material 
for tying arteries, etc. 
Arterial hemorrhage is best arrested by simple 
ligation, and a ligature is occasionally required 
in venous bleeding. It is best to include as little 
of the surrounding tissues as possible in employ- 
ing a ligature, except when arterial coats are 
diseased. In ovariotomy the pedicle is included 
in the ligature with the vessels en masse. Hemor- 
rhoids and naevi may be treated by ligature. Silk 
linen thread, silkworm-gut, kangaroo tendon 
Age. 
Number 
Living. 
Num- 
ber 
Dying. 
Yearly 
Probability 
of Dying. 
Expec- 
tation 
of Life. 
1 Age. 
Number 
Living. 
Num- 
ber 
Dying 
Yearly 
Probability 
of Dying. 
Expec- 
tation 
of Life. 
10 
10Q.000 
676 
0.006760 
48.36 
55 
63,469 
1375 
0.021664 
16.86 
11 
99,324 
674 
0.006786 
47.68 
56 
62,094 
1436 
0.023126 
16.22 
12 
98,650 
672 
0.006812 
47.01 
57 
60,658 
1497 
0.024679 
15.59 
13 
97,978 
671 
0.006848 
46.33 
58 
59,161 
1561 
0.026386 
14.97 
14 
97,307 
671 
0.006896 
45.64 
59 
57,600 
1627 
0.028246 
14.37 
15 
96,636 
671 
0.006943 
44.96 
60 
55,973 
1698 
0.030336 
13.77 
16 
95,965 
672 
0.007003 
44.27 
61 
54,275 
1770 
0.032612 
13.18 
17 
95,293 
673 
0.007062 
43.58 
62 
52,505 
1844 
0.035120 
12.61 
18 
94,620 
675 
0.007134 
42.88 
63 
50,661 
1917 
0.037840 
12.05 
19 
93,945 
677 
0.007206 
42.19 
64 
48,744 
1990 
0.040826 
11.51 
20 
93,268 
680 
0.007291 
41.49 
65 
46,754 
2061 
0.044082 
10.97 
21 
92,588 
683 
0.007377 
40.79 
66 
44,693 
2128 
0.047614 
10.46 
22 
91,905 
686 
0.007464 
40.09 
67 
42,565 
2191 
0.051474 
9.96 
23 
91,219 
690 
0.007564 
39.39 
68 
40,374 
2246 
0.055630 
9.47 
24 
90,529 
694 
0.007666 
38.68 
69 
38,128 
2291 
0.060087 
9.00 
25 
89,835 
698 
0.007770 
37.98 
70 
35,837 
2327 
0.064933 
8.54 
26 
89,137 
703 
0.007887 
37.27 
71 
33,510 
2351 
0.070158 
8.10 
27 
88,434 
708 
0.008006 
36.56 
72 
31,159 
2362 
0.075805 
7.67 
28 
87,726 
714 
0.008139 
35.86 
73 
28,797 
2358 
0.081883 
7.26 
29 
87,012 
720 
0.008275 
35.15 
74 
26,439 
2339 
0.088468 
6.86 
30 
86,292 
727 
0.008425 
34.43 
75 
24,100 
2303 
0.095560 
6.48 
31 
85,565 
734 
0.008578 
33.72 
76 
21,797 
2249 
0.103179 
6.11 
32 
84,831 
742 
0.008747 
33.01 
77 
19,548 
2179 
0.111469 
5.76 
33 
84,089 
750 
0.008919 
32.30 
78 
17,369 
2092 
0.120444 
5.42 
34 
83,339 
758 
0.009095 
31.58 
79 
15,277 
1987 
0.130065 
5.09 
35 
82,581 
767 
0.009288 
30.87 
80 
13,290 
1866 
0.140406 
4.78 
36 
81,814 
776 
0.009485 
30.15 
81 
11,424 
1730 
0.151436 
4.48 
37 
81,038 
785 
0.009687 
29.44 
82 
9,694 
1582 
0.163194 
4.18 
38 
80,253 
795 
0.009906 
28.72 
83 
8,112 
1427 
0.175912 
3.90 
39 
79,458 
805 
0.010131 
28.00 
84 
6,685 
1268 
0.189678 
3.63 
40 
78,653 
815 
0.010362 
27.28 
85 
5,417 
1111 
0.205095 
3.36 
41 
77,838 
826 
0.010612 
26.56 
86 
4,306 
958 
0.222480 
3.10 
42 
77,012 
839 
0.010894 
25.84 
87 
3,348 
811 
0.242234 
2.84 
43 
76,173 
857 
0.011251 
25,12 
88 
2,537 
673 
0.265274 
2.59 
44 
75,316 
881 
0.011697 
24.40 
89 
1,864 
545 
0.292382 
2.35 
45 
74,435 
909 
0.012212 
23.69 
90 
1,319 
427 
0.323730 
2.11 
46 
73,526 
944 
0.012839 
22.97 
91 
892 
322 
0.360987 
1.89 
47 
72,582 
981 
0.013516 
22.27 
92 
570 
231 
0.405263 
1.67 
48 
71,601 
1021 
0.014260 
21.56 
93 
339 
155 
0.457227 
1.47 
49 
70,580 
1063 
0.015061 
20.87 
94 
184 
95 
0.516304 
1.28 
50 
69,517 
1108 
0.015939 
20.18 
95 
89 
52 
0.584270 
1.12 
51 
68,409 
1156 
0.016898 
19.50 
96 
37 
24 
0.648649 
0.99 
52 
67,253 
1207 
0.017947 
18.82 
97 
13 
9 
0.692308 
0.89 
53 
66,046 
1261 
0.019093 
18.16 
98 
4 
3 
0.750000 
0.75 
54 
64,785 
1316 
0.020313 
17.50 
99 
1 
1 
1.000000 
0.50 LIGATURE 
hemp, catgut, ox aorta, fine wire, horse-hair, 
and other materials have been used for ligature. 
Silk, silkworm-gut, and catgut are the materials 
most used. Dentists' floss has been recommended 
when large vessels are to be tied, since it does 
not easily slip. For sutures, silk or silkworm-gut 
is best. Silver and other wire sutures are not 
much employed. For cut ends of arteries catgut, 
properly prepared, is likely the best ligature 
material. Chromicized catgut is harder than 
ordinary catgut, and requires soaking in carbolic 
lotion for an hour before use. It then ceases to 
be slippery or brittle, and its knot will not yield. 
Animal ligatures disappear in course of time, while 
silk ligatures remain and may set up irritation. 
A single thread should always be used for ligation 
of arteries. 
Preparation of Catgut.-Dry sterilization of 
catgut seemed to become the general procedure 
a few years ago, but extensive trial has shown that 
it cannot be relied upon in rendering the material 
absolutely safe for practical use. The many 
failures of catgut as an aseptic suture and ligature, 
as heretofore prepared, are responsible for the 
substitution of silk for catgut in the practice of 
many surgeons. Instances of even tetanus in- 
fection have been traced to the use of catgut. 
Silk can be readily sterilized by boiling, the 
simplest and quickest method of effecting absolute 
sterilization. 
The ideal sterilization of catgut consists in 
rendering the material not only absolutely sterile, 
but also mildly antiseptic, without impairing 
its tensile strength. Every surgeon has been 
anxiously looking for a method by which catgut 
could be prepared so that it could be sterilized by 
boiling without impairing its strength. Experi- 
ments have shown that catgut and leather im- 
mersed for 48 hours in a 2 to 4 percent solution of 
formalin undergo an unknown chemic change, 
which alters their texture in such a way that its 
tensile strength is not impaired, but rather in- 
creased, by boiling. The commercial catgut is 
subjected to the action of the formalin without 
any previous preparatory treatment of the raw 
material. Hofmeister, who has done such excel- 
lent service in perfecting the formalin preparation 
of catgut, gives the following most recent method: 
(1) The catgut is wound on a glass plate with 
slightly projecting edges, so that the gut is free 
from the sides of the plate and exposed to the 
circulation of the boiling and flowing water. 
The ends of the gut are fastened through holes 
in the plate. (2) Immersion 12 to 48 hours in 
aqueous solution of formalin 2 to 4 percent. 
(3) Immersion in flowing water at least 12 hours 
to free the gut from the formalin. (4) Boiling 
in water from 10 to 30 minutes. Ten to 12 minutes 
are amply sufficient, as all microbes and spores 
are killed by exposure to boiling heat for that 
length of time. (5) Hardening and preservation 
in absolute alcohol containing 5 percent of glycerin 
and 0.1 percent of corrosive sublimate. 
One of the essential conditions of success in 
this method of catgut sterilization is to wind 
the gut quite tightly around the glass plate 
LIGATURE 
or hollow glass cylinder during the process of 
sterilization. 
The result of Senn's experience has led him to 
modify the procedure in several ways. Instead 
of glass plates, ordinary glass abdominal drainage- 
tubes have been employed, upon which the gut 
is wound quite tightly. These glass drains have 
been found an excellent substitute for the plates. 
An ordinary large test-tube would answer the 
same purpose. The remaining directions given by 
Hofmeister were followed to the letter. Num- 
erous inoculations with fragments of catgut pre- 
pared by this method in sterile gelatin invariably 
gave negative results. The catgut is as strong as 
the raw material, hard, and the knot is less liable 
to slip than when the ordinary material is used. 
In the preparation of catgut Senn has modified 
Hofmeister's method by substituting iodoform 
for the corrosive sublimate. After boiling the 
deformalinized catgut for 12 to 15 minutes, 
it is cut into pieces of desirable length, tied into 
small bundles containing from 6 to 12 threads, 
when it is immersed and kept ready for use in the 
following mixture: Absolute alcohol 950, glycerin 
50, iodoform (finely pulverized) 100. The alcohol 
dissolves part of the iodoform. The bottle con- 
taining the catgut should be closed with a well- 
fitting glass cork and should be shaken well every 
few days to bring the dissolved iodoform in contact 
with the threads. The catgut can be kept in this 
mixture for any length of time without losing its 
strength. One of the valuable properties of 
iodoform applied to a recent wound is to diminish 
the amount of primary wound secretion. It does 
not destroy pus microbes, but inhibits their 
growth. 
Silk may be prepared by boiling, after having 
been wound on glass spools, and kept in an ordin- 
ary test-tube, the mouth of which has been stop- 
pered by sterile absorbent cotton. Before use 
it should be resterilized. It may be put in a 
carbolic solution, 1:20, to which two-thirds of its 
quantity of alcohol has been added. This is 
better than corrosive sublimate solution, since the 
needles may be threaded and placed in the liquid 
together with the ligature. 
Kangaroo tendon has the advantage over catgut 
in being uncontaminated by germs when obtained 
from a healthy freshly-killed animal. It is very 
carefully prepared and dried and may be kept 
indefinitely in carbolic acid (1 to 20). The strands 
are especially valuable for large blood-vessels and 
varicoceles and deep-buried sutures of the abdom- 
inal wall, hernia and muscular union. They are 
absorbed in about 6 weeks. 
Horsehair washed with ether and sterilized by 
heat is excellent for skin sutures when there is 
not much tension. 
Silkworm-gut is commonly used by anglers. It 
may be purchased in bundles, and from them 
suitable pieces should be picked for surgical use. 
As a rule, pharmacists keep selected material for 
surgical use. It may be sterilized by heat or it 
may be soaked in a carbolic solution for 15 minutes 
before use. The first knot should be a double one, 
and the second knot tied very lightly or not at all, LIGHTNING, INJURIES 
LINSEED 
to obviate breakage. It is an excellent interrupted 
skin suture, but not adapted for vessels and deep 
tissues by reason of its remaining rigid and 
unabsorbed. 
Silver wire is used for skin sutures when there 
is much tension, and combined with lead for bone 
suture. Its polished surface has the advantage 
of not attracting germs. 
The method of tying a ligature is as follows: 
Usually a reef knot is used. See Knot. The 
fingertips should be pressed down on the ligature 
surrounding the vessel, to obviate the danger of 
lifting up the artery from its bed. The ends 
should be cut short. Absolute cessation of pulsa- 
tion of the artery below the ligature denotes 
sufficient ligation, but if the vessel is diseased, the 
knot should be made most deliberately. The 
preparation of ligatures is also discussed in the 
article on Abdominal Section (q. v.). See also 
Arteries (Ligation). . 
LIGHTNING, INJURIES.-In nonfatal injuries 
sudden collapse, with unconsciousness, is followed 
by drowsiness, fever, much prostration, and 
occasionally by delirium and convulsions. Paral- 
ysis of one or more limbs, severe neuralgic pains, 
impairment of vision, and even blindness are results. 
Along list of sequels, due to progressive inflam- 
matory changes and shock, has been recorded. 
Superficial injuries show spots of ecchymosis, 
burns greatly varying in extent and severity, and 
dusky patches due to fused buttons, chains, 
studs, etc. Arrest of the growth of the hair is 
another result of injury from lightning. The 
mortality of injuries from lightning is about 25 
percent. When a person is killed suddenly, the 
body either falls at once to the ground or becomes 
rigid and remains fixed in a more or less erect at- 
titude. Such a person may not present a visible 
mark of injury or the body may be mutilated and 
the bones of limbs or cranium widely comminuted 
and exposed. The clothes may be untouched or 
be reduced to shreds and torn away. Rigor 
mortis comes on rapidly in fatal cases. Instances 
of rupture of the heart and of the stomach have 
been recorded. 
The treatment of the resultant shock consists in 
the application of warmth to the surface of the 
body; the administration of stimulants by mouth, 
rectum, or hypodermically, and, when necessary, 
the use of artificial respiration. Local lesions re- 
quire their proper treatment, for which see 
Burns, Electricity (Injuries). Burns caused 
by lightning heal very slowly. Paralyses ensuing 
often yield to the influence of galvanism when 
properly and regularly given. 
LIGHT THERAPY.-See Phototherapy. 
LIME.-The popular name for calcium oxid, 
CaO (quicklime), and calcium hydroxid, Ca(HO)2. 
Calcium oxid (quicklime) has a great affinity for 
water and for CO2. On contact with the former, 
slaked lime is formed, with the evolution of heat. 
On living tissues it acts as a caustic. L., Burnt, 
L., Caustic, calcium oxid, quicklime. L., Chlorid 
of, L., Chlorinated, the chlorid of lime of commerce, 
is not a distinct chemic compound; its chief 
constituent, and the one on which its disinfectant 
properties depend, is calcium hypochlorite, which 
liberates chlorin. L., Milk of, a milky fluid 
consisting of calcium hydroxid suspended in water. 
L., Quick-, L., Slaked, common terms for lime. 
L. Ointment, an ointment consisting of slaked 
lime, 4; lard, 1; and olive oil, 3. L.-water, a solu- 
tion of calcium hydroxid in water. It is astringent 
and alkaline and prevents the formation of dense 
coagula if added to milk. Dose, 4 to 8 drams. 
L., Syrup of {syrup of calcium hydroxid)-contains 
6 1/2 percent of lime, and 40 of sugar, the latter 
aiding the solvent power. Dose, 10 to 60 minims. 
It is an antidote to poisoning by oxalic acid and 
phenol. L., Liniment (Carron oil)-contains equal 
volumes of lime-water and linseed oil, mixed by 
agitation. For local use. 
Lime-water is a useful antacid. In diabetes, in 
uric acid diathesis, and in excessive nausea and 
vomiting, teaspoonful doses of milk and lime- 
water will be retained when nothing else will 
remain on the stomach. Lime-water is given in 
the dose of 1 dram to 2 ounces. Externally, lime- 
water is used in tinea capitis, and in burns when 
mixed with equal parts of linseed oil or olive oil, 
forming carron oil. In membranous croup and in 
diphtheria lime-water is useful as a spray or on a 
swab. Lime-water is made by pouring 2 quarts of 
boiled and filtered water upon a piece of unslaked 
lime about the size of a walnut. After stirring and 
allowing to settle in an earthen jar, the clear liquid 
is poured off for use. See Calcium. 
LINIMENTS (Linimenta).-Very thin ointments 
for external application, intended to be applied 
with friction to the skin. They are solutions of 
various substances in oily liquids or in alcoholic 
liquids containing fatty oils. There are 8 official 
liniments. 
Official Liniments.- 
Title. 
Base. 
Constituents. 
Linimentum: 
Ammonia (am- 
Cottonseed 
Ammonia water, 350 
monia), 
oil. 
c.c.; alcohol, 50 c.c.; 
cottonseed oil, 570 c. c.; 
oleic acid, 30 c.c. 
Camphor, 50 gm.; fldext. 
(Volatile Lini- 
ment) , 
Belladonna (bel- 
Alcohol 
ladonna), 
Calcis (carron oil), 
Linseed oil.... 
belladonna, to make 
1000 c.c. 
Lime water, Enseed oil, 
Camphoree (cam- 
Cottonseed oil. 
equal parts. 
Camphor, 200 gm.; cot- 
phor), 
Chloroformi 
Alcohol 
tonseed oil, 800 gm. 
Chloroform, 300 c.c.' 
(chloroform), 
Saponis (soap),.. 
Alcohol 
soap liniment, 700 c.c. 
Soap (gran.), 60 gm.; 
Saponis mollis 
Alcohol 
camphor, 45 gm.; oil 
rosemary, 10 c.c.; al- 
cohol, 725 c c.; water to 
make 1000 c.c. 
Soft soap, 650 gm.; oil 
(soft soap). 
Terebinth in® 
Oil of turpen- 
lavender flowers, 20c. c.; 
alcohol, to make 1000 c.c. 
Rosin cerate, 650 gm.; 
(turpentine). 
tine 
oil turpentine, 350 gm. 
-- ■ 
LINSEED (Flaxseed).-The seed of Linum 
usitatissimum (flax), a cultivated annual plant. 
It contains 15 percent of mucilage in the epithe- LINT 
LIPS, DISEASES 
lium, also 30 to 40 percent of fixed oil in the embryo. 
Ground linseed should yield not less than 25 per- 
cent of the fixed oil. 
Therapeutics.-Linseed is demulcent, emollient, 
expectorant, and diuretic. The oil is laxative in a 
dose of 1 ounce, and in smaller doses is oxidized in 
the system. The infusion contains the mucilagin- 
ous principle and a small portion of the oil, and is 
advantageously used in inflammations of the 
mucous membrane of the throat, the gastrointes- 
tinal tract, and the urinary passages. It is an 
excellent demulcent in coughs of various kinds, 
and will be found very serviceable in cystitis, 
irritable bladder, renal colic, strangury, etc. The 
oil may be administered internally as a laxative, 
and has considerable reputation as a remedy for 
hemorrhoids in doses of 2 ounces twice daily. For 
laxative purposes (especially in children) it is 
usually administered as an enema. Externally 
it is a favorite application to burns, when made 
into an emulsion with lime-water. The ground 
seed (linseed or flaxseed meal) is one of the best 
agents for making poultices, and is universally 
employed for that purpose, though it is objection- 
able from an aseptic point of veiw. 
To make a linseed poultice, the following 
materials must be collected: (1) A sheet of tow, a 
folded flannel or cloth-in an emergency a sheet of 
brown' paper or large cabbage-leaf-spread out on 
a table or board, and a little larger than the part to 
be poulticed; (2) a bowl and spoon; (3) the crushed 
linseed; (4) a kettle and boiling water. Warm 
the basin and spoon by pouring into the former 
some boiling water, and empty it out. Put in 
some meal and add a very little hot water. Stir 
into a paste with the heated spoon. Continue 
doing this until enough paste to cover the tow has 
been made. It should now be spread 1/4 inch 
thick evenly and flatly to within 1 inch of the 
edges of the tow or cloth, which edges are folded 
up to form a margin. Too much or too little water 
is harmful, making the poultice soft and sloppy or 
sticky. The poultice should be made at the bed- 
side, and the linseed placed next to the skin, and 
removed after 2 hours. See Flaxseed; Poultice. 
Preparations.-L., 01., the fixed oil of linseed 
expressed cold; a glycerid of linoleic acid. Dose, 
1/2 to 2 ounces. Carron Oil, linseed oil emulsified 
in lime-water; used for burns. 
LINT.-A loosely woven or partly felted mass of 
broken linen-fibers, made by scraping and "pick- 
ing" old linen cloth. It is used as a dressing for 
wounds and raw surfaces. Common lint is twilled 
on one side and "woolly" on the other. In the 
spreading of an ointment the twilled side is used. 
LIPEMIA.-See Blood. 
LIPOMA.-A fatty tumor. See Tumors. 
LIPS, DISEASES. Herpes.-A crop of herpetic 
vesicles which burst in a few days, leaving a scab, 
is common upon the lips, especially in gastric and 
febrile disturbances. The vesicles may be moist- 
ened with alcohol, cologne water, camphor water, 
or smeared with alum, zinc ointment, boric oint- 
ment, etc. 
Cracks and fissures of the lip following exposure 
to cold, etc., in dyspeptics, are very common, and 
if neglected, may form deep and painful fissures, 
prone to bleed and obstinate to heal. A simple 
ointment, and, if persistent, touching them with 
silver nitrate, will generally suffice to cure them. 
They must not be mistaken for the fissures about 
the corners of the mouth so common in congenital 
and acquired syphilis. 
Papillomata or warty growths of the lips are of 
interest in that they are liable, as age advances, to 
become epitheliomatous. They may sometimes 
grow out in the form of horns. Extirpation with 
the knife is the proper treatment. 
Superficial ulcers on the inner surface of the lip 
are common accompaniments of errors in digestion 
and of secondary syphilis. There are usually 
similar ulcers on the side of the tongue and cheeks. 
Silver nitrate or chromic acid lotions are the best 
local applications. 
Nevus of the lip, when small, may be touched 
with nitric acid or sodium ethylate; and when 
pendulous and projecting from the free margin, 
ligated. When involving the whole substance of 
the lip, it may be treated by electrolysis, or, better, 
excised by means of a V-shaped incision. 
Hypertrophy of the lip, generally the upper, is 
often met with in connection with cracks and 
fissures in strumous children, and is known as the 
strumous lip. A similar condition is sometimes 
met in congenital syphilis and in chronic nasal 
catarrh. The thickening, as a rule, disappears 
under constitutional treatment and as the patient 
grows older. The removal of a wedge-shaped 
piece, as advised by some, is seldom necessary. 
Carbuncle of the lip is a most dangerous disease, 
as it is very likely to lead to infective phlebitis of 
the facial vein, which may spread thence through 
the ophthalmic vein to the cavernous and other 
cranial sinuses, and terminate in infective menin- 
gitis or in general blood-poisoning. Free incisions 
should be made, the sloughs scraped away, anti- 
septics applied, and the strength supported by 
fluid nourishment and stimulants. 
Adenoma or labial glandular tumor (Paget) 
occasionally occurs in the lip as small, smooth, 
elastic growths projecting under the mucous mem- 
brane. It sometimes contains nodules of car- 
tilage, and is then of harder consistency. It 
should be removed from the mucous surface to 
avoid scarring. 
Cysts due to obstruction of the mucous follicles 
are frequent in the lip. They contain a glairy 
fluid, and appear as small, tense, semitranslucent, 
globular, bluish-pink swellings on the mucous sur- 
face. A free incision through the mucous mem- 
brane, and removal of the cyst-wall with forceps, 
is perhaps the best treatment. 
Mucous patches are sometimes observed on the 
mucous surfaces of the lips, most frequently at the 
angle of the mouth or in the groove between the 
gums and lips. They are usually superficial, not 
elevated, and present the appearance as if a silver 
nitrate stick had been drawn across the surface; 
the latter circumstance has given rise to the term 
"opaline patches." When situated at the angle 
of the mouth, they may become fissured, painful, 
and bleeding. Their surrounding area lacks the LIQUID AIR 
LIQUOR 
semblance of acute inflammation, being somewhat 
dull and congested; this fact proves important in 
differentiating them from the patches of aphthous 
stomatitis. The previous history, the adenopathy, 
the presence, perhaps, of a cutaneous lesion, and 
the resistance to ordinary local treatment would 
serve to render the diagnosis clear. See Syphilis. 
Epithelioma nearly always occurs in men, and 
on the lower lip; and although it may affect non- 
smokers, it generally appears to be due to the 
irritation and heat of a short clay pipe. It begins 
as a crack, small ulcer, or indurated tubercle, and 
may either spread superficially along the free 
margin of the lip or extend deeply into its sub- 
stance. Sooner or later it involves the whole lip 
and adjoining parts, becomes adherent to the jaw, 
and invades the bone. The lymphatic glands in 
the neck become involved, but dissemination 
through internal organs is rare. If removed early, 
it may not recur until after a long period of im- 
munity or, perhaps, not at all. It seldom returns 
in the scar, but in the lymphatic glands, the pa- 
tient dying of exhaustion induced by ulcerating 
and bleeding masses in the neck. 
Diagnosis.-The affection is likely to be mis- 
taken for hard chancre, and the latter has been cut 
away under the impression that it was an epithe- 
lioma. The following points should serve in 
diagnosis: (1) Epithelioma generally occurs in 
the old, and in men, and on the lower lip; chancre 
in the young, in women, and on the upper lip. 
(2) The epitheliomatous ulcer has hard, sinuous, 
and everted edges, and an indurated and warty 
base; the chancrous is raised, excoriated, smoother, 
and the induration is more circumscribed. (3) 
In the malignant affection the glands are not 
affected until late in the disease-perhaps 6 
months; in the syphilitic, early-say 6 weeks. 
Moreover, in chancre secondary symptoms will 
be present or soon appear, and the disease readily 
yields to antisyphilitic remedies. See Epitheli- 
oma. 
Treatment.-Free and early excision is impera- 
tive. The growth may be either included in a 
V-shaped incision, the wound being afterward 
united by harelip pins, or, if superficial, freely 
shaved off. The glands in the neck, if enlarged 
and not too extensively diseased, should be extir- 
pated at the same time. When the bone is in- 
volved, a portion of the jaw may be removed if the 
whole disease can be exterminated. 
Harelip.-See Harelip. 
LIQUID AIR (Carbon Dioxid Snow).-See Air, 
Liquid. 
LIQUOR.-In pharmacy any solution in water 
of nonvolatile substances, except infusions, decoc- 
tions, syrups. There are 25 official solutions: 
Liquor Acidi Arsenosi. Should contain arsenous 
acid, corresponding in amount to 1 percent of 
arsenic trioxid. Medical properties same as 
Fowler's solution. Average dose, 3 minims. 
Liquor Ammonii Acetatis (spirit of Mindererus). 
An aqueous solution which should contain not less 
than 7 percent of ammonium acetate, together 
with small amounts of acetic and carbonic acids. 
Diaphoretic in fevers. Average dose, 4 drams. 
Liquor Antisepticus. (Similar to listerine, etc.) 
Boric acid, 20 gm.; benzoic acid, 1 gm.; thymol, 
1 gm.; eucalyptol, 0.25 c.c.; oil of peppermint, 0.50 
c.c.; oil of gaultheria, 0.25 c.c.; oil of thyme, 0.10 
c.c.; alcohol, 250 c.c.; purified talc, 20 gm.; water, 
to make 1000 c.c. Average dose, 1 dram. Liquor 
Arseni et Hydrargyri lodidi (solution of arsenic and 
mercuric iodid) (Donovan's solution). Contains 1 
percent of each of the active ingredients. Alterative. 
Average dose, 11/2 minims. Liquor Calcis (solu- 
tion of calcium hydrate; lime water). A saturated 
solution. Antacid, tonic and astringent. Aver- 
age dose, 4 drams. Liquor Chlori Compositus. 
Compound solution of chlorin. Chlorin water. 
(To replace Aqua Chlori, U. S. P., 1890.) An 
aqueous solution containing, when freshly pre- 
pared, about 0.4 percent of chlorin with some oxid 
of chlorin and potassium chlorid. Average dose, 1 
dram. Liquor Cresolis Compositus. (Similar to 
lysol.) Cresol, 500 gm.; linseed oil, 350 gm.; 
potassium hydroxid, 8 gm.; water to 1000 gm. 
Liquor Ferri Chloridi. An aqueous solution of 
ferric chlorid which should contain not less than 
29 percent of the anhydrous salt, corresponding 
to 10 percent of metallic iron. Average dose, 11/2 
minims. Used in preparing tincture of ferric 
chlorid; also externally as a styptic to arrest 
hemorrhage. Liquor Ferri et Ammonii Acetatis 
(Basham's mixture). Contains in each thousand 
c.c. Tr. Ferri. Chlor. 40 c.c., Acid Acetic Dil. 60 
c.c., Sol. Ammon. Acet. 500 c.c., Aromat. Elix. 120 
c.c., glycerin 120 c.c., water to 100 c.c. Actively 
chalybeate, also astringent, and very largely used 
in Bright's disease. Average dose, 4 drams. 
Liquor Ferri Subsulphatis (solution of basic ferric 
sulphate, Monsel's solution). An aqueous solution 
of variable chemical composition, containing an 
amount of basic ferric sulphate corresponding to 
not less than 13.57 percent, of metallic iron. 
Styptic to bleeding surfaces; used internally in 
hemorrhage of stomach and bowels. Average 
dose, 3 minims. Liquor Ferri Tersulphatis. An 
aqueous solution which should contain about 35 
percent of normal ferric sulphate, corresponding to 
not less than 10 percent of metallic iron. Used 
for preparing other iron preparations, as in the 
preparation of the antidote for arsenic. Liquor 
Formaldehydi (formalin). An aqueous solution, 
containing not less than 37 percent by weight of 
absolute formaldehyd. Liquor Hydrargyri Nitra- 
tis. A liquid which should contain about 60 
percent of mercuric nitrate, and about 11 percent 
of free HN03. Caustic application to chancre, etc. 
Liquor lodi Compositus (Lugol's solution). Should 
contain not less than 5 percent iodin, 10 percent 
potassium iodid. Average dose, 3 minims. 
Liquor Magnesii Citratis. Made by dissolving 33 
gm. citric acid in 120 c.c. of water and adding 15 
gm. magnesium carbonate; dissolving; filtering 
into a bottle holding 360 c.c. (containing 120 c.c. 
syrup of citric acid), adding enough water to nearly 
fill the bottle, dropping in 2.5 gm. potassium 
bicarbonate; shaking until dissolved; corking, 
and securing the cork with twine. Average dose, 
12 drams. Liquor Plumbi Subacetatis. (Some- 
times called Goulard's extract.) An aqueous LIQUOR AMNII 
liquid, containing not less than 25 percent of lead 
subacetate. Used externally as a sedative in 
sprains, etc., when dilute, from 1/2 or 1 part to 16 
parts distilled water. Liquor Plumbi Subacetatis 
Dilutus (lead water). Contains 4 percent of the 
stronger lead water. Astringent and sedative 
externally. Liquor Potassii Arsenitis (Fowler's 
solution). An aqueous solution which should 
contain potassium arsenite corresponding in 
amount to 1 percent of arsenic trioxid, formed 
by the combination of arsenous acid with potas- 
sium of the potassium bicarbonate (carbon dioxid 
being evolved). Compound spirit of lavender is 
added to give it taste, and prevent its being mis- 
taken for water; 100 minims equal about 1 grain 
arsenic. Average dose, 3 minims. Liquor Potassii 
Citratis (Mistura Potassii Citratis). An aqueous 
liquid, containing in solution not less than 8 
percent of anhydrous potassium citrate, together 
with small amounts of citric and carbonic acids. 
Made by dissolving separately potassium bicar- 
bonate and citric acid, and afterward mixing the so- 
lution, under the names neutral mixture, saline mix- 
ture, or effervescing draught; long used as a refriger- 
ant diaphoretic. Average dose, 4 drams. Liquor 
Potassii Hydroxidi. (Liquor Potassae, U. S. P., 
1880.) An aqueous solution containing about 5 
percent of potassium hydroxid. Average dose, 
15 minims. Liquor Sodae Chlorinatae (Labar- 
raque's solution). An aqueous solution of several 
chlorin compounds of sodium, containing at least 
2.4 percent by weight of available chlorin. Stim- 
ulant, antiseptic, and resolvent. Average dose, 
15 minims. Also, use locally for fetor, etc. A 
powerful disinfectant. Liquor Sodii Arsenatis. 
Should contain sodium arsenate correspond- 
ing in amount to not less than 1 percent 
of exsiccated sodium arsenate. Average dose, 
3 minims. Liquor Sodii Hydroxidi. (Liquor 
Sodae, U. S. P., 1890.) An aqueous solution con- 
taining about 5 percent of sodium hydroxid. 
Average dose, 15 minims. Liquor Sodii Phospha- 
tis Compositus. Sodium phosphate, 1000 gm.; 
sodium nitrate, 40 gm.; citric acid, 130 gm.; dis- 
tilled water, to 1000 c.c. Average dose, 2 drams. 
Liquor Zinci Chloridi. An aqueous solution con- 
taining about 50 percent by weight of zinc chlorid. 
A substitute for Burnett's disinfecting fluid. 
Used locally to disinfect fetid discharges; also 
employed for preserving anatomical specimens. 
LIQUOR AMNII.-See Amnii (Liquor). 
LIQUORICE.-See Glycyrrhiza. 
LITHEMIA.-Modified gout. A condition in 
which, owing to defective metabolism of the nitrog- 
enous elements, the blood becomes charged with 
deleterious substances, principally, perhaps, of 
the uric acid group, although their exact chemic 
nature is not determined. See Uric Acid, Gout, 
Rheumatism. 
LITHIA.- Li2O. Oxid of lithium, an alkaline 
caustic. L. Water, mineral water containing 
lithium salts in solution. Among the best known 
in the United States are the Buffalo lithia water, 
water from Buffalo Lithia Springs, Mecklenburg 
County, Ya.; Farmville lithia water, from Farm- 
ville, Va.; Londonderry lithia water, from 
Londonderry, N. H. The proportion of bicar- 
bonate of lithium contained in the 3 waters men- 
tioned is as follows: Londonderry, 8.620; Buffalo, 
1.484 to 2.25; Farmville, 1.99. 
LITHIUM.-Li = 7; quanti valence, 1. One of 
the rarer alkaline metals, a few of the salts only 
being used in medicine. Because of its low atomic 
weight, its high saturating power makes its salts 
more highly alkaline than those of sodium and 
potassium. The carbonate and citrate are used 
largely in rheumatism and gout. L. Benzoas. 
Dose, 5 to 20 grains. L. Bromidum. See Bromin. 
Dose, 5 to 20 grains. L. Carbonas, not deliques- 
cent. Dose, 2 to 15 grains. L. Citras, deliques- 
cent. Dose, 5 to 20 grains. L. Citras Effer- 
vescens, effervescent lithium citrate, prepared 
from citrate 5, with sodium bicarbonate 57, tar- 
taric acid 30, citric acid 19 1/2. Dose, 1 to 3 
drams in water, as an effervescent drink. L. 
Salicylas. See Salicylic Acid. Dose, 5 to 20 
grains. 
LITHOLAPAXY.-See Bladder (Stone). 
LITHONTRIPTICS.-See Antilithics. 
LITHOTOMY.-See Bladder (Stone). 
LITMUS.-A blue pigment obtained from 
Rocella tinctoria, a lichen. It is employed in chemic 
determinations to detect the presence of acids and 
alkalies. Blue litmus paper is unsized paper 
steeped in a solution of litmus; it turns red on 
contact with acid solutions. Red litmus paper 
is unsized paper steeped in litmus tincture, colored 
red with acid; it turns blue on contact with alkaline 
solutions. See Acidity, Alkalinity, Urine 
(Examination). 
LITTER.-The following qualities are essential 
for a litter or stretcher: 1. Firm and comfortable 
support for the patient, and capability of being 
readily cleansed. 2. Lightness. 3. Strength. 
4. Simplicity of construction. 5. Capability of 
being folded up, if possible. 6. Such connection 
of component parts as to prevent risk of loss. 
7. Provision for keeping patient a certain distance 
above ground when the litter is laid down. 8. 
Economy. 
A two-handed seat or litter may be devised by 2 
bearers facing each other, locking the fingers of the 
left hand of one with the fingert of the right hand 
of the other. The support is placed beneath the 
patient's thighs in front of the buttock for a seat, 
the disengaged hands resting upon and grasping 
each other's shoulders behind the patient, and 
thus forming a back support. The arms of the 
patient may be passed around the neck of each 
bearer. 
A three-handed seat may be made by 2 persons 
facing each other, the thick part of the forearm 
just below the elbow of one being grasped by his 
right hand and with the left hand the left forearm 
of the other being grasped. This left forearm now 
grasps the right forearm of the other bearer at 
about its middle. The right hand of the second 
bearer grasps the left shoulder of the other bearer 
to form a back support. The seat formed is a 
triangular one, and is formed by the 3 forearms. 
A four-handed seat is made by 2 bearers grasping 
their own left forearms with their own right 
LITTER LIVE BIRTH, TESTS 
LIVER, ABSCESS 
hands at or about their wrists. The left hand of 
each grasps the right forearm of the other. 
Swords in their scabbards may be passed through 
the sleeves of a coat turned inside out and the 
coat skirts buttoned from below upward, for 2 
or 3 buttons over the sleeves incasing the swords. 
Improvised stretchers or litters may be made out 
of hurdles, shutters, or planks. In the 2 latter 
cases straps, ropes, or wooden traverses must 
be passed beneath, between 2 bearers at the head 
and 2 at the feet. 
A rifle litter may be made with a blanket or 
rug, 2 rifles being laid on the ground at each side 
and the blanket folded over them. 
LIVE BIRTH, TESTS.-See Viability. 
LIVER, ABSCESS (Suppurative Hepatitis).- 
Etiology.-Abscess of the liver is probably 
always of microbic origin. The infection may 
reach the liver by way of the hepatic artery, 
from ulcerative endocarditis, general septicemia, 
etc.; or the hepatic vein; or the common duct. 
Secondary to a suppurative cholangitis set up 
by biliary calculi or parasites, but generally it 
enters vid the portal vein in the form of an in- 
fectious thrombus or embolus or the ameba coli. 
Thus septic emboli from suppurative appendi- 
citis, gastric ulcer or dysentery may enter the 
liver. In most instances, however, abscess of 
the liver is due to the ameba coli and is preceded 
by amebic dysentery, though in some amebic 
abscesses there are no intestinal symptoms. 
Occasionally it results from infective traumatism. 
It may be secondary to an infected hydatid cyst. 
See Colon Bacillus Infection. 
Pathology.-In two-thirds of the cases of abscess 
of the liver the middle portion of the right lobe 
is affected. The abscess varies in size and may 
be either single or multiple. Amebic abscess is 
usually single and large, while pyemic metastatic 
abscesses are small and multiple. Frequently 
both lobes are involved and the liver may be 
greatly increased in size. The pus may be reddish 
in color or creamy, and frequently it is sterile. 
The abscess may rupture into the bowel, abdominal 
cavity, or bronchi. 
Symptoms and Clinical Course.-There are 
probably many cases of abscess of liver which 
are never diagnosed, owing to the latency of many 
of the symptoms in the early stages. The first 
subjective symptoms probably are: Pain in the 
right hypochondriac region, or region of the right 
scapula, of a deep-seated character; gradual de- 
cline of health with loss of flesh; intermittent, 
irregular high fever 105° F.; rapid and feeble pulse 
and frequent chills, followed by profuse perspira- 
tion. Hectic symptoms may be present. These 
are the classic symptoms of infection, yet they do 
not lead us to the correct diagnosis, and frequently 
the physical signs are distinctly misleading. 
Physical Signs.-Inspection frequently detects 
bulging in the right hypochondrium, and slight 
jaundice. 
Palpation detects enlargement and a deep- 
seated pain. Frequently there is an edematous 
condition over the affected part, and fluctuation 
may be present if the abscess is superficial. If 
the lower portion of the right lobe is affected, the 
enlargement extends downward. In the early 
stages the area is hard, but later, as the disease 
advances, it softens and may give rise to fluctua- 
tion. 
Percussion detects an increased area of dulness 
in the direction of the portion involved. Osler 
states that the enlargement is most frequently 
upward, and that at the nipple-line the curve of 
liver dulness begins to rise and in the midaxillary 
Abscess of Liver. 
Hepatic Intermittent 
Fever. 
Cancer. 
Malarial Fever. 
Hydatid Cyst. 
Subjective Symptoms 
Subjective Symptoms. 
Subjective Symptoms. 
Subjective Symptoms. 
Subjective Symptoms, 
1. History of trauma- 
tism, dysentery. 
1. History of hepatic 
colic and transient 
jaundice. 
1. Often in h eri te d 
tendency. 
1. History of malarial 
exposure. 
1. History negative 
2. Pain in region of 
right hypochondriac re- 
gion or right scapula. 
2. Same as abscess.... 
2. Same as abscess.... 
2. Pain slight or ab- 
sent. 
2. Pain absent. 
3. Intermittent, irregu- 
lar, high fever, with 
sweat and chills not 
controlled by quinin. 
3. Same as abscess.... 
3. Same as abscess.... 
3. Temperature con- 
trolled by quinin. 
3. Temperature normal. 
Objective Symptoms. 
Objective Symptoms. 
Objective Symptoms. 
Objective Symptoms. 
Objective Symptoms. 
1. Jaundice slight 
1. Jaundice intense.... 
1. Jaundice 
1. No jaundice 
1. Jaundice usually ab- 
sent. 
2. Bulging in right hy- 
pochondrium. 
2. Negative 
2. Negative 
2. Negative 
2. Bulging in epigastric 
or hypogastric region. 
3. Liver enlarged and 
3. Liver slightly de- 
3. Liver enlarged and 
3. Liver may be 
3. Liver dulnessincreased 
smooth; occasionally 
edema and fluctuation 
in right hypochondrium. 
creased in size. 
nodular. 
slightly enlarged and 
smooth. Spleen en- 
larged. 
in area. 
4. Percussion confirms 
palpation. 
4. Same 
4. Increased area of 
dulness. 
4. Percussion confirms 
palpation. 
4. Percussion often de- 
tects a vibratory sensa- 
tion. 
5. Aspiration detects pus. 
5. Negative 
5. Negative 
5. Negative; plasmo- 
dium in blood con- 
firms diagnosis. 
5. Aspiration detects 
clear fluid containing 
glucose. LIVER, ABSCESS 
LIVER, ACUTE YELLOW ATROPHY 
line it may reach the fifth rib, while behind, 
near the spine, the area of dulness may be so 
high as to be on a level with the angle of the 
scapula. 
Diagnosis depends upon the subjective and 
objective symptoms. 
Prognosis is unfavorable. 
Treatment.-If the pain is severe, opium, 1 
grain, is advisable every 4 hours. Locally, a hot- 
water bag, mustard plaster, or hot turpentine 
stupes may afford some relief. The bowels should 
be kept open by means of salines. 
Stimulants, such as whisky, 4 drams, are al- 
lowable every 4 hours, if necessary. Quinin, 4 
grains, with dilute nitrohydrochloric acid, 6 
minims, may be of benefit. 
Medicines, as a rule, are only palliative, and 
surgical measures give a better chance for recovery. 
Surgical Treatment.-(1) If the skin over the 
swelling is red and pits on pressure, there can be 
little doubt either as to the existence of an abscess 
or to the presence of adhesions. In such circum- 
stances an aspirating needle may be used as a pre- 
liminary, to act as a guide, but as soon as it has 
entered the cavity and the diagnosis is confirmed, 
the opening should be enlarged, so that the pus 
can escape as freely as possible, and a full-sized 
drainage-tube inserted. The following day, when 
the adhesions are firmer, the abscess cavity may 
be explored with the finger to make sure there are 
no other sacs in the immediate neighborhood, and, 
if necessary, washed out with iodin or some other 
antiseptic. (2) When there is no certainty as to 
the presence of adhesions the choice lies between 
aspiration, drainage with a trocar and cannula, and 
incision (Tyson). 
Aspiration is chiefly of use for exploration; it 
rarely happens that an abscess cavity is completely 
emptied, and nearly always the swelling appears 
again within a few days. In a few instances, how- 
ever, a cure has followed after 2 or 3 repetitions. 
Puncture with a trocar and cannula is also open to 
grave obj ections. If adhesions are present already, 
it is more satisfactory to make a free incision and 
allow of thorough exploration and drainage; if 
they are not, the peritoneal cavity is opened with- 
out any safeguard to prevent the pus entering it. 
Further, the constant movement of the liver in the 
abdominal cavity frequently renders the retention 
of a tight-fitting cannula or of a stiff drainage-tube 
a matter of very considerable difficulty. 
Incision directly into the abscess sac can only be 
practised when the skin over it is reddened and it 
is certain that the walls are adherent. If this is 
not definite, either the operation must be carried 
out in separate stages, or an incision made into 
the abdomen over the swelling, the surface of the 
liver exposed, and the abscess opened with the 
usual precautions to prevent its contents entering 
the peritoneal cavity. The preliminary steps are 
the same in both, but while in one the incision is 
only carried down to the parietal peritoneum, and 
is then plugged, so that adhesions may form be- 
neath, in the other the abdominal cavity is opened 
at once and the surface of the liver examined. In 
a few cases omentum has been interposed, or it 
has been found that the abscesses are multiple and 
that there is no hope of thorough evacuation; but 
if no difficulty of this kind is apparent, the wound 
is carefully packed around with sponges, and an 
aspirating needle thrust into the swelling. As 
soon as the pus is found, the opening is enlarged 
freely with the knife, and the contents of the ab- 
scess allowed to escape completely; the assistant, 
meanwhile, carefully supporting the liver on either 
side, so that it shall not fall away from the surface 
of the abdomen. When the sac is emptied, the 
cavity may be explored with the finger and the 
walls stitched to the skin margins of the wound all 
around. An aspirating needle may be thrust 
through the two layers of the pleura and diaphragm 
for the sake of exploring the posterior surface 
of the liver without risk; but if a permanent drain 
is required, a free incision should be made down to 
the parietal pleura, a portion of one of the ribs 
being resected if necessary, the two layers of the 
pleura accurately sutured together with catgut 
(there is no difficulty in this in the lower intercostal 
spaces), and then the trocar and cannula thrust 
through, so as to avoid the risk of air or pus enter- 
ing into the pleural space. 
LIVER, ACUTE YELLOW ATROPHY.-A fatal 
form of disease of the liver, characterized anatomi- 
cally by a rapid destruction of the liver cells, dim- 
inution in size of the organ, and associated with 
deep jaundice and grave nervous symptoms. 
Synonyms.-Malignant jaundice, acute paren- 
chymatous hepatitis, icterus gravis. 
Etiology.-(1) Female sex; (2) pregnancy; (3) 
infectious fevers; (4) alcoholism; (5) mental ex- 
citement. An acute toxemia may be the main 
exciting cause. 
Pathology.-The liver is greatly reduced in size, 
often not more than one-third the usual volume 
during health. This rapid destruction may take 
place within the course of a few days, or from 1 to 
2 weeks. The organ is soft, yellowish in color in 
the early stages, but later may be reddish (red 
atrophy). The capsule may be wrinkled. Micro- 
scopically, fatty degeneration of the liver cells 
occurs, taking place first in the periphery and later 
extending toward the center of the lobule. There 
is also fatty degeneration of the epithelial cells of 
the biliary ducts. The destroyed liver cells and 
epithelial cells subsequently undergo liquefaction 
necrosis and are rapidly absorbed, causing shrink- 
age of the organ. If the disease persists, there is a 
hyperplasia of the connective tissue, and the color 
becomes mottled. 
Symptoms and Clinical Course.-The initial 
symptoms occupy a period of 2 or 3 days, and are 
marked by headache, loss of appetite, nausea and 
vomiting, gastric distress, jaundice, and, later, 
delirium or convulsions. Hemorrhages from the 
mucous membranes may occur, and hematemesis 
is common. The liver is rapidly reduced in size, 
while the spleen is considerably enlarged. The 
urine is deeply bile-stained, of high specific gravity 
(1030), slightly albuminous, containing fatty casts, 
leucin, and tyrosin. 
Diagnosis.-See Liver (Cirrhosis). 
Prognosis.-The disease is always fatal. LIVER, AMYLOID 
LIVER, CIRRHOSIS 
Treatment is supportive and palliative. 
LIVER,[AMYLOID.-An enlargement of the liver 
due to infiltration of the tissues by an amyloid 
substance. 
Synonyms.-Lardaceous liver; waxy liver; albu- 
minoid liver. 
Etiology.-(1) Prolonged suppuration as in 
tubercular bone-disease; (2) syphilis; (3) leuke- 
mia; (4) rickets. 
Pathology.-The liver is enlarged and smooth; 
the cut surface is semitranslucent (waxy), and 
resembles in appearance boiled bacon. The amy- 
loid deposit is found mainly in the central portion 
of the lobules. The initial process seems to be in 
the capillary blood-vessels, which are often coated 
with a hyaline material. 
The amyloid substance is not deposited to so 
great an extent in the liver cells, but they may un- 
dergo fatty degeneration from want of a free blood 
supply. 
Symptoms and Clinical Course.-The liver is 
smooth in contour and greatly enlarged, and may 
reach the umbilicus. There is no pain or jaundice. 
Ascites is absent except in the last stages. The 
spleen shares in the process and is greatly enlarged. 
Often the kidney becomes affected by the albu- 
minoid infiltration, giving rise to albumin in the 
urine. 
Diagnosis rests upon the history of the case; 
great enlargement of the liver and spleen; absence 
of jaundice, ascites, hectic symptoms, and the 
presence of albumin in the urine. From leukemia 
it must be differentiated by a blood examination. 
Prognosis is unfavorable. 
Treatment must be directed to the underlying 
cause. 
LIVER, CARCINOMA. Etiology.-(1) Male sex 
after the fortieth year; (2) usually secondary from 
neighboring organs. 
Pathology.-The organ is enlarged in size, the 
liver tissue being brownish or yellowish in color. 
Instead of the surface being smooth, it is generally 
irregular or nodular. 
Varieties.-(1) Nodular form; (2) radiating form; 
(3) massive form. 
In the nodular form there are small whitish areas 
or elevations which project from the external 
surface. 
The radiating form produces multiple nodules 
that are pigmented. It is usually secondary. 
In the massive form the disease is diffused 
throughout the whole organ, causing great en- 
largement. The color is usually grayish-white. 
The nodules may be hard or soft, the larger ones 
often showing a degree of fatty degeneration, and 
may give rise to extravasation of blood into the 
parenchyma. 
Both the large and small nodules project slightly 
above the serous surface, and in the former variety 
a degree of umbilication may be seen. 
Symptoms and Clinical Course.-There are 
severe pain over the region of the liver, persistent 
vomiting, cachexia with rapid loss of flesh and 
strength, and great anemia (red cells moderately 
reduced, 4,000,000; hemoglobin may be only 
50 percent; moderate leukocytosis). Jaundice is 
nearly always present. Ascites is usually absent. 
There is moderate fever-101° to 103° F. 
Physical Signs.-Palpation detects tenderness, 
and frequently nodular growths on the free border 
of the liver. 
Percussion confirms palpation, and shows an 
increased area of dulness in all directions. It also 
shows the presence of cancer in neighboring organs 
(stomach, pancreas, etc.). 
Diagnosis.-See Liver (Abscess). 
Prognosis.-The duration is from 3 to 15 months. 
Treatment is symptomatic and palliative. 
LIVER, CIRRHOSIS. Synonyms.-Chronic in- 
terstitial hepatitis, hob-nail liver, gin liver, gran- 
ular liver. 
A disease characterized by hyperplasia of the 
connective tissue, with a destruction to a greater 
or less extent of the parenchymatous cells, the 
liver being firmer in consistency. 
Etiology.-(1) Male sex; (2) middle life; (3) 
alcoholism; (4) chronic malarial poisoning; (5) 
congenital syphilis; (6) passive hyperemia re- 
sulting from heart or lung disease; (7) gall 
stones; (8) rich diet; (9) cause unknown. The 
causes may act through the portal vein, the he- 
patic arteries, hepatic vein, or the biliary ducts. 
It seems probable, as Weigert has shown, that the 
cells irritated undergo degeneration and die, 
their place being taken by connective tissue over- 
growth, the subsequent contraction of which 
causes still more destruction of the secreting cells. 
Varieties.-(1) Atrophic; (2) hypertrophic. 
Atrophic Cirrhosis. Synonyms.-Portal cirrho- 
sis; Laennec's cirrhosis. 
Pathology.-The liver is much smaller and harder 
than normal and its surface is usually roughened 
with small granulations or nodules, though some- 
times it is smooth, owing to a uniform distribution 
of the connective tissue. The elevations, when 
present, are due to the contraction of bands of 
connective tissue which have taken the place of 
parenchyma, and which surround normal areas of 
secreting cells. The entire surface is yellowish 
or mottled if the cells are fatty. Associated with 
the cirrhosis is frequently found fatty infiltration. 
The increase in size of the liver due to the latter 
condition may predominate over the reduction 
resulting from the cirrhosis. As the disease ad- 
vances retrograde changes involve also the branches 
of the portal vein, and even the biliary ducts, 
causing obstruction in the portal circulation and 
ascites. 
Hypertrophic Cirrhosis. Synonym.-Hanot's 
cirrhosis. 
Pathology.-In this form the hyperplastic 
connective tissue has not the tendency to contract 
that it exhibits in the atrophic. Therefore, the 
liver is enlarged but smooth. Its color is gener- 
ally yellowish-green. It is believed that the con- 
nective tissue overgrowth takes place especially 
within the lobules. The branches of the portal 
vein are not encroached upon, but there is ob- 
struction of the biliary channels resulting in 
jaundice. 
Biliary Cirrhosis.-A distinct form according to 
French clinicians, is believed by some observers LIVER, CIRRHOSIS 
LIVER, CIRRHOSIS 
to be identical with the hypertrophic variety. 
It is secondary to obstruction in the gall ducts. 
The retention of bile in the ducts leading to destruc- 
tion of the parenchymatous cells, their place is 
taken by a proliferation of the interstitial connec- 
tive tissue. There is a deposit of pigment. The 
organ becomes larger and harder. 
Symptoms of Atrophic Cirrhosis.-In the early 
stages of cirrhosis of the liver symptoms may be 
absent. The onset is gradual, the initial symptoms 
being due to obstructed portal circulation which 
produces chronic gastrointestinal catarrh, with its 
run of symptoms-coated tongue, anorexia, 
nausea, flatulence, constipation. Deficiency in 
the amount of bile secreted is evidenced by the pale 
stools. As the compression of vessels increases 
there is a compensatory dilatation of the collateral 
vessels, as manifested by hemorrhoids, the over- 
distended superficial abdominal veins, which may 
be especially pronounced around the umbilicus, 
forming the caput medusae. Similarly, there result 
gastric, intestinal, or esophageal hemorrhages; en- 
largement of spleen, ascites, and even edema of 
the lungs. Slight jaundice from obstruction of 
the bile ducts is present in about one-fourth of 
the cases, but its absence may be due to the paucity 
of the biliary secretions. There is progressive loss 
of flesh and strength. Uterine or nasal hemor- 
rhages, or even hematuria may appear. Nervous 
signs, such as stupor, delirium, coma, sometimes 
supervene late in the disease. 
Physical examination reveals a smaller area of 
hepatic dulness with increased splenic dulness. 
The urine is usually scanty, highly colored, of 
high specific gravity, with abundance of urates, re- 
duction in amount of urea and only infrequently 
contains biliary pigment. 
Symptoms of Hypertrophic Cirrhosis.-Jaundice 
is generally present, because of some obstruction in 
the biliary vessels. The liver is not only enlarged 
and smooth, but tender. There is usually little or 
no enlargement of the spleen, nor gastrointestinal 
congestion, nor ascites, nor hemorrhoids-. The 
stools are sometimes pale, at others normal in 
color. The urine, although scanty and highly 
colored, frequently contains biliary pigment, while 
the quantity of urine is normal. There is a marked 
reduction in the number of red blood cells and 
increase in the number of leukocytes. 
Complications.-Concomitant increase in the 
connective tissue of heart, lungs, blood-vessels, 
autointoxication from suppression of biliary 
secretion. 
Diagnosis.-(1) Of Atrophic Cirrhosis. 
In the early stages diagnosis is uncertain; but it 
is clear when reduction in size of the organ is found, 
associated with ascites. The emaciation and 
effusion of tuberculous peritonitis may be confus- 
ing, but, in the latter disease, the effusion is not 
so abundant and is of higher specific gravity, and 
there is abdominal tenderness and fever, and no 
reduction in the size of the liver. If doubt exists, 
the tuberculin test should be resorted to. 
(2) Of Hypertrophic Cirrhosis. 
Hypertrophic cirrhosis must be differentiated 
from chronic biliary obstruction, cancer of liver, 
amyloid liver, multilocular echinococcus cyst. In 
the secondary cirrhosis of chronic biliary obstruc- 
tion the liver is not so enlarged, the course is more 
rapid and is attended with attacks of hepatic 
colic. In carcinoma the patient is older, with 
no alcoholic habit, or enlargement of the spleen, 
the liver is not so smooth, ascites is more general. 
In amyloid liver there is the characteristic etiology 
and no pain or jaundice. In hydatid disease the 
nodules on the surface become soft. 
Prognosis.-The duration of hypertrophic cir- 
rhosis is from 1 to 2 years. Atrophic cirrhosis 
has a longer coma. Fatal terminal symptoms, 
such as rapid pulse, fever, delirium, may appear 
rather suddenly. The disease, however, is not 
always fatal; if the process be not too far advanced 
and the cause, such as alcohol, removed, the 
patient may indeed recover tolerably good health. 
Usually, however, death ensues from exhaustion 
and toxemia. 
Treatment.-The chief objects to be attained 
are the removal of the cause, the relief of the 
symptoms and restitution of the normal con- 
ditions in the liver. Alcohol must be interdicted. 
The gastrointestinal catarrh should receive care- 
ful attention. The diet should be nutritious, yet 
simple so as not to tax the more or less impaired 
digestion. Fats should be restricted and too much 
starchy food should not be allowed for fear of 
setting up additional fermentation. The free 
drinking of alkaline mineral waters, especially 
when hot, or of simple hot waters, before meals, 
particularly before breakfast, is valuable to re- 
move the excessive mucus. The extensive fer- 
mentation may be alleviated by internal anti- 
septics, such as sodium phenolsulphonate or 
phenyl salicylate. 
Depletion by salines or minerals is indicated. 
For instance 5 to 10 grains of blue mass at night 
followed in the morning by sodium phosphate 
or Hunyadi water one-half hour before breakfast, 
will relieve the congestion. Calomel in doses 
of 1/10 grain, frequently repeated, is excellent. 
Laxative mineral waters, such as Saratoga 
water, have a similar effect. Occasionally it is 
well to alternate with the salines cascara sagrada, 
or compound jalap powder. A diminution of the 
ascites effected by this treatment is further aided 
by diuretics. The potassium salt to be preferred 
is the acetate in doses of 20 grains t. i. d. 
citrated caffein may be given in doses of 2 to 5 
grains. Theobromin has proved valuable in the 
hands of some observers. 
Abdominal paracentesis, or tapping, must be em- 
ployed when the effusion is sufficiently large to 
cause discomfort or additional symptoms of pres- 
sure. Frequently repeated treatment may be 
necessary, as the fluid may speedily reaccumulate. 
Surgical Treatment of the Ascites.-Talma's 
operation-omentopexy-suture of the parietal 
peritoneum of the abdomen and omentum to the 
liver, to relieve the liver conditions by the estab- 
lishment of a collateral circulation between the por- 
tal and systemic vessels has been found effective 
if not resorted to too late. 
Attempts to check the progress of the degenera- LIVER, CONGESTION 
LIVER, EXAMINATION 
tive changes and to effect repairs have been for 
the most part futile. lodin in some form should be 
tried, especially if a specific origin is suspected. 
Potassium iodid is given for a long time in doses 
of 3 to 10 grains, well diluted, and on an empty 
stomach. Some observers prefer the syrup of 
hydriodic acid, 1 dram, well diluted, one-half 
hour before food. Other drugs, such as ammonium 
chlorid and nitrohydrochloric acid, have been used. 
Organotherapy is advocated by certain French 
clinicians. 
LIVER, CONGESTION. Varieties.-(1) Active; 
(2) passive. 
Etiology. Active Hyperemia.-(1) Overindul- 
gence in food or drink; (2) warm climate; (3) 
infectious fevers. "Biliousness" is probably 
a form of active hypbremia. 
Passive hyperemia usually results from valvular 
disease of the heart, disease of the lungs or pleura, 
or pressure on the vena cava. 
Pathology.-The liver is enlarged in size from 
congestion of the blood-vessels. The organ is 
bluish-red or brownish-red in color. In certain 
areas the intralobular vein is filled with dark blood, 
while the adjacent capillaries are empty and 
opaque, giving rise to a mottled appearance- 
"nutmeg liver." 
If of long standing, an overgrowth of the con- 
nective tissue occurs with a considerable amount of 
pigmentation and atrophy of the hepatic cells, 
giving rise to a condition called "cyanotic indu- 
ration." 
Symptoms and Clinical Course. Active Hyper- 
emia.-There is anorexia, dull headache, mental 
hebetude, coated tongue, bitter, disagreeable 
taste in the mouth, feeling of nausea, often vomiting 
of material containing the biliary salts, fever, 
constipation or diarrhea in which the feces have 
a distinctly greenish color and cause great 
tenesmus. The urine is high-colored and scanty. 
Hemorrhoids are frequently produced. 
Passive Hyperemia.-There is great enlargement 
of the organ, due to stagnation of the blood; and 
if the right heart is affected, there is often distinct 
pulsation in the liver. 
Prognosis.-In active hyperemia the prognosis 
is good. In passive congestion, as there is dis- 
ease in other organs, the prognosis is less 
favorable. 
Treatment of Active Hyperemia.-Rest in bed 
and a liquid diet are demanded. Of many reme- 
dies recommended, calomel holds the first place. 
It is best given in small doses, 1/4 of a grain, every 
hour until 6 or 7 doses have been taken, and fol- 
lowed by a saline purge if the bowels do not move 
within 10 or 12 hours. If there is much pain in 
the right hypochondriac region, a series of small 
blisters, 1 by 2 inches, may be produced by means 
of cantharidal plaster, or the red iodid of mer- 
cury, 40 grains, with petrolatum, 1 ounce. In the 
more chronic forms the fats and foods containing 
sugar must be restricted. Frequent bathing and 
plenty of out-door exercise are invaluable. 
Constipation may often be relieved by proper 
regimen, and the use of the fluidextract of cascara, 
1/2 of a dram, at bedtime. Nitrohydrochloric 
acid, 6 minims, combined with pepsin, 5 grains, 
may afford relief. 
The elixir of the phosphates of iron, quinin, and 
strychnin, 1 dram, is frequently beneficial. 
Treatment of passive hyperemia must be directed 
mainly to the underlying cause. Depletion may 
be produced by rest in bed, a light diet, and a 
saline purge every day or two. A series of blisters 
may also afford some refief. See Heart-disease, 
E PHRITIS 
LIVER, EXAMINATION. Boundaries.-The 
liver is the largest gland in the body, weighing 
from 3 to 4 pounds. Its upper portion is convex 
and directed upward and forward; it is smooth 
and covered with peritoneum. The upper surface 
is in .immediate relation with the under surface 
of the diaphragm. Its under surface is concave, 
directed downward and backward, and in relation 
with the stomach, duodenum, hepatic flexure of 
the colon, right kidney, and suprarenal capsule. 
The upper surface of the liver is divided into 
2 unequal lobes-the right and the left. 
The right lobe of the liver occupies the right hypo- 
chondrium, the upper border anteriorly extending 
from the base of the ensiform cartilage on the 
median line, in the fifth intercostal space on the 
right nipple-line, in the seventh intercostal space 
in the axillary line, and posteriorly below the base, 
of the right lung, about the level of the tenth rib 
or dorsal spine. The lower border of the right 
lobe normally should not extend below the free 
margin of the ribs. 
The left lobe of the liver occupies the epigastric 
region, extending 2 inches to the left of the median 
line, the lower margin usually being found im- 
mediately overlying the stomach and about 3 
inches below the ensiform cartilage. The left 
lobe is in close relation with the heart, being sepa- 
rated from that organ through the medium of the 
diaphragm. 
Inspection.-By this method of diagnosis we 
detect general jaundice and enlargement in the 
right hypochondrium. Bulging may be present in 
hydatid cyst and distended gall-bladder. Jaun- 
dice is present in catarrhal jaundice, biliary cal- 
culi, cancer, hypertrophic cirrhosis, acute yellow 
atrophy, and occasionally in acute hepatitis. 
Palpation.-The patient should be in a dorsal 
position, with the shoulders elevated and the knees 
drawn up. 
The liver is enlarged and smooth in amyloid 
disease, fatty liver, congestion of the liver, hyper- 
trophic cirrhosis, and multiple abscesses. It is 
enlarged but uneven in hydatid tumor, single 
abscess, and cancer. 
Palpation detects pain which is present in acute 
congestion, catarrhal jaundice, biliary calculi, 
abscess, and cancer. Edema may be present in 
the right hypochondrium in hepatic abscess. 
Fluctuation may be detected in hydatid cyst and 
distended gall-bladder, and occasionally in ab- 
scess of liver. 
The liver is diminished in size in atrophic cirrhosis 
and acute yellow atrophy. 
Percussion.-The patient should be placed in a 
dorsal position. By percussion tile size of the LIVER, HYDATID CYST 
liver is obtained. The upper boundary of the 
organ is determined by first gently tapping over the 
right nipple to detect the lung resonance, then 
gradually going downward until the upper edge 
of the liver is found. In the axilla the same 
method is pursued. The upper boundary of the 
right lobe in the nipple-line will be found in the 
fifth intercostal space, in the axillary line in the 
seventh interspace, and posteriorly on a line with 
the tenth rib or tenth dorsal spine. The lower 
border of the liver extends to, but not beyond, the 
free margin of the ribs anteriorly. The left lobe 
of the liver may often be outlined by gentle per- 
cussion. The upper border is inseparable from the 
dulness of the heart. The lower border lies about 
2 inches to the left of the median line, and ex- 
tends downward midway between the ensiform 
cartilage and the umbilicus. 
Examination in Children.-Douchez says: The 
exact determination of the borders of the liver in 
children is difficult, because of the involuntary con- 
traction of the muscles, also on account of the 
resonance found over the thin lower edge and of 
the oblique position of the upper border. 
The measure of dulness of the anterior face of the 
liver, in the living, is almost always less by 1 or 2 
centimeters than the real measure on the cadaver, 
either before or after opening the abdomen; we 
should, therefore, estimate this dulness from its 
extreme limits, in order to reach as nearly as 
possible the truth. 
The upper border of the liver corresponds in gen- 
eral to the interval between the fifth and sixth ribs. 
In the healthy state, the vertical measurements 
increase almost regularly with each year's growth, 
excepting in certain individuals. 
The liver was found somewhat large in cases of 
catarrhal jaundice and gastric disturbance; large 
in cardiac disease; very large with amyloid liver, 
syphilitic liver, fatty liver, and hydatid cysts. 
The slightest disturbance of health may cause a 
variation of 2 to 4 centimeters, and a variation of 
3 to 10 centimeters was found with certain grave 
lesions. 
LIVER, HYDATID CYST. Etiology and Path- 
ology.-Hydatid cysts are formed by the larvae of 
the taenia echinococcus of the dog. This tape-worm 
is exceedingly small, provided with 4 sucking discs 
and a double row of booklets (Osler). The eggs 
usually gain entrance through the mouth, and 
after the shell has become detached, the embryo is 
set free, and, becoming attached to the intestinal 
wall, may burrow its way to the external surface. 
It probably gains entrance to the liver through the 
medium of the portal vein. After a certain time 
the embryo develops into a cyst with two layers- 
the internal (breeding) or granular layer, and the 
external (dense) or laminated layer. Daughter 
cysts spring from the inner or granular layer; 
hence the process is a continuous one. The daugh- 
ter cysts may be set free; hence there may be 
hundreds within the primary cyst. The investing 
membrane of the smaller growths is soft, thin, and 
gelatinous, containing a clear, nonalbuminous 
fluid of specific gravity 1005-1007, rich in chlorids 
and containing glucose. 
LIVER, SARCOMA 
Symptoms and Clinical Course.-In the early 
stages no symptoms are produced. Later, as the 
cysts multiply and the fluid accumulates, there is 
an irregular enlargement of the liver, producing a 
dragging sensation in the right hypochondrium, 
dyspnea, and palpitation of the heart. Fever and 
pain are only present if there is suppuration of the 
cyst. 
Jaundice is generally absent, but may result if 
pressure is great enough to cause occlusion of the 
biliary ducts. Percussion over the area yields a 
vibratory or trembling movement. By aspiration 
the clear-colored fluid is obtained. 
Complications.-Suppuration, metastasis to 
various organs, as lung, pleura, brain, spinal canal, 
and genitals. 
Diagnosis.-See Liver (Abscess). 
Prognosis is unfavorable as to medicinal treat- 
ment. Surgical interference yields favorable re- 
sults. 
Treatment is purely surgical. See Liver (Ab- 
scess). 
LIVER, INJURIES.-See Abdomen (Wounds 
and Injuries), Gunshot Wounds. 
LIVER, PERIHEPATITIS.-Inflammation of 
the peritoneal covering of the liver. 
Etiology.-(1) Extension, by continuity, of 
hepatic inflammation; (2) extension of pleurisy, 
by contiguity; (3) secondary to ulcer of stomach, 
etc.; (4) as part of a general peritonitis. 
Pathology.-In the acute type there is fibrinous 
or purulent exudation with formation of adhesions. 
Thus, between the liver and diaphragm a pocket 
filled with pus may be formed, i. e., a subphrenic 
abscess. 
In the chronic form the capsule of the liver is 
thickened, especially at the hilum, with stenosis 
of the blood-vessels and bile ducts, and shrinkage 
of the liver, while adhesions to neighboring organs 
may occur. 
Symptoms.-None are characteristic; often it is 
unsuspected in life. Sometimes the symptoms 
resemble atrophic cirrhosis. Physical examination 
may disclose a friction-rub over the liver or epi- 
gastrium. If there is purulent exudation, symp- 
toms, and signs of sepsis manifest themselves. 
Diagnosis.-It is to be distinguished from an 
empyema by the early symptoms, which are 
abdominal rather than thoracic and accompanied 
by further downward displacement of the liver. 
Aspiration may be resorted to, and it is said that 
the spurting of the released fluid is synchronous 
in subphrenic abscess with inspiration, in empy- 
ema with expiration. The nonpurulent form is 
rarely recognized until death. 
Prognosis is grave in the suppurative form. 
Treatment.-Before pus formation, bed, light 
diet, counterirritation by cupping or leeching, 
hot compresses, sinapisms are indicated. Sur- 
gery is necessary as soon as pus is manifest. 
LIVER, SARCOMA.-Sarcoma of the liver is rare. 
In 1908, Knott was able to collect from the litera- 
ture only fifty-nine cases in which it occurred as a 
primary lesion. It may occur at any time of life 
from infancy to old age. The tumor grows rapidly 
and constitutional symptoms soon develop. It is LIVER, SYPHILIS 
musty; should it become offensive, decomposition 
and, probably, sepsis have occurred. 
LOCKJAW.-See Tetanus. 
LOCOMOTOR ATAXIA (Tabes Dorsalis; 
Posterior Spinal Sclerosis).-Posterior spinal 
sclerosis is perhaps the preferable designation for 
the affection under consideration, because the 
most constant and the most conspicuous lesion 
is essentially that which this name describes. 
Although the disorder is the most common and the 
most important of the diseases of the spinal cord, it 
has been well recognized and differentiated only 
during the past sixty years. 
Pathologic Anatomy.-The essential lesion is a 
more or less extensive degenerative process, of 
varying intensity, involving the paths for conduct- 
ing sensory impressions, which is most pronounced 
and most conspicuous in the posterior nerve-roots 
and the posterior columns of the spinal cord. 
Macroscopically, the degenerated portions of the 
cord appear grayish or slightly pinkish and trans- 
lucent, and somewhat depressed below the com- 
mon level. The overlying pia mater may be tur- 
bid and slightly thickened. The differentiation 
between diseased and healthy structure is brought 
out more vividly by staining. 
On microscopic examination the disease is found 
to begin on either side in the posterior nerve-roots, 
and to extend into the posteroexternal columns of 
Burdach, while at higher levels the posterointernal 
columns of Goll are also involved. A small area 
in the posterior columns, adjacent to the posterior 
commissure, invariably escapes, while an oval area, 
adjacent to the posterior median fissure, and a 
comma-shaped zone included between the columns 
of Burdach and those of Goll, remain long intact. 
Histologic study shows the axis-cylinders to 
have disappeared from the degenerated areas par- 
tially or wholly, while the glia remains or has even 
undergone hyperplasia. The walls of the blood- 
vessels in the affected portions are thickened. The 
disease of the spinal cord is not confined to the 
white matter. In addition to the posterior roots 
the posterior vesicular columns of Clarke, the 
marginal zone of Lissauer, and the medullary 
bridge of Weigert also suffer sometimes. Further, 
the degenerative process may involve the gan- 
glia of the posterior spinal nerves, whose medul- 
lated fibers and ganglion cells may be in part 
destroyed. Peripheral sensory nerves also have, 
in a number of instances, been found diseased. 
Sometimes, too, the cerebral nerves and the nuclei 
situated in the medulla oblongata participate in 
the degenerative process. The morbid process 
usually begins, and is most common and most pro- 
nounced, in the dorsolumbar region of the cord, 
but a cervical and a cerebral type of the disease 
are also sometimes described. 
Etiology.-Posterior spinal sclerosis is a disease 
of middle life, one-half of the cases occurring 
between 30 and 40 years, and almost all between 
20 and 50 years. It is exceedingly uncommon in 
early life, and it rarely begins in late life. It is 
more common in men than in women, in the pro- 
portion of about 10 to 1; and in the larger cities 
than in the smaller towns. It is rare in negroes, if 
LOCOMOTOR ATAXIA 
practically impossible to differentiate sarcoma 
from carcinoma when the disease affects a person in 
middle or advanced life. Unless the neoplasm is 
distinctly circumscribed no attempt should be 
made to remove it. 
LIVER, SYPHILIS.-Syphilis of the liver is usu- 
ally a tertiary lesion, although it may occur early in 
the secondary stage, as an acute diffuse low grade 
inflammation, causing considerable enlargement 
of the gland, and sometimes giving rise to jaundice. 
The prognosis of this form is usually good, active 
mercurial treatment bringing about complete 
resolution. 
Tertiary syphilis may affect the liver either as an 
interstitial inflammation or in the form of single 
or multiple gummata. Interstitial hepatitis is 
similar to atrophic cirrhosis in many respects. 
The cellular infiltrate is changed into connective 
tissue which compresses the ducts and blood- 
vessels, with resulting atrophy of the hepatic cells. 
Gummata are usually multiple and vary greatly 
in size. 
For both tertiary forms of the disease large doses 
of potassium iodid together with mercurial inunc- 
tions or injections should be given. Gummata 
not relieved by such treatment have been excised or 
fixed to the abdominal wall, the interior scooped out 
and a strip of gauze inserted (Spencer and Gask). 
LOBELIA.-The leaves and tops of L. inflata, 
an expectorant, diaphoretic, purgative, antispas- 
modic, and emetic; in larger doses a motor depres- 
sant and narcotic. It contains gum, resin, fixed 
oil, wax, lignin, salts of calcium, potassium, and 
iron, a liquid alkaloid, lobelin, also lobelic acid, and 
lobelacrin. Dose, 2 to 15 grains. 
Lobelia has an acrid, nauseous taste, and heavy, 
unpleasant odor. It strongly resembles tobacco 
in its action. It is useful in paroxysmal spasmodic 
asthma, as well as in dry cough with constant 
tickling in the throat. As an enema in strangulated 
hernia, the infusion is safer than tobacco, and as 
efficient. In constipation from atony and deficient 
secretion, 10 minims of the tincture at bedtime 
will be found to act well. 
Preparations.-Fluidextractum L. Dose, 1 to 15 
minims. Tinctura L., 10 percent. Dose, as expecto- 
rant 5 to 20 minims; as emetic 1/2 to 2 drams. 
Infusum L., gj to a pint. Dose, 1 to 8 drams. 
LOCHIA.-The bloody, serous discharge from 
the uterus after labor. For the first 4 or 5 days 
it is bright red in color (lochia rubra), and com- 
posed chiefly of blood. During the next few days 
it becomes lighter in color {lochia serosa), and is 
composed of some blood, pus, mucus, and serous 
discharge. Finally it becomes white or yellowish 
{lochia alba), and resembles an ordinary vaginal leu- 
korrhea. The flow ceases entirely at the end of 3 
to 6 weeks. 
The amount of the flow varies considerably in 
different individuals and at different times. Or- 
dinarily, 4 to 6 napkins are saturated in the 24 
hours for the first 3 or 4 days; after that the num- 
ber varies from 1 to 3 until the ninth or tenth day, 
when the discharge becomes so slight as not to 
requirep a rotective. 
The odor of the normal lochia is bloody or LOCOMOTOR ATAXIA 
LOCOMOTOR ATAXIA 
it occurs at all in the full black. Heredity, direct 
and indirect, exerts but little, if any, etiologic influ- 
ence. The most potent, though scarcely the sole, 
cause is syphilis, albeit it must be borne in mind 
that even then the lesions themselves are not syph- 
ilitic. Among additional, though far less impor- 
tant, etiologic factors, are other infectious and 
toxic processes, exposure to wet and cold, trauma- 
tism, and excesses of various kinds. A long inter- 
val-from 5 to 20 years-often elapses between 
the incidence of the causative condition and the 
appearance of the first symptoms of the spinal 
disease, though cases have been reported in which 
the separation has been as short as 1 year and as 
long as 20 years respectively. Hereditary syph- 
ilis has been the antecedent condition in a small 
number of cases. The disease, further, is occa- 
sionally observed in the sequence of other affec- 
tions of the spinal cord: e. g., myelitis, gumma. 
Duration and Course.-Posterior spinal sclerosis 
is essentially a chronic and progressive disease. 
It is often insidious in onset, and it may advance 
slowly. Not rarely there are remissions, some- 
times with long stationary periods. Occasionally, 
the disease pursues a relatively acute course. 
Once established, however, recovery is out of the 
question. The duration is, as a rule, protracted, 
and may cover many years. The disease is not 
fatal of itself, death resulting from complications 
or intercurrent disease. Its course may be divided 
into three periods: (1) neuralgic; (2) ataxic; (3) 
paraplegic. 
The prognosis is relatively favorable as to life, 
but distinctly unfavorable with regard to recovery, 
although arrest of the disease may take place at 
any stage. 
Symptomatology.-The symptoms of posterior 
spinal sclerosis concern especially and almost 
exclusively the sensory functions of the nervous 
system, and they may represent any degree of 
disturbance, from mere diminution to absolute 
loss. Among the earliest are shooting pains in the 
thighs, the so-called lightning or lancinating pains. 
These usually occur in paroxysms of varying dura- 
tion (from hours to days), at longer or shorter inter- 
vals (from days to months). The pains may be 
boring, tearing, cutting, or burning, and they are 
sometimes present in the upper extremities, and 
rarely in other portions of the body. Possibly 
allied to these, although commonly they occur at a 
later period of the disease, are the painful parox- 
ysmal seizures known as crises: laryngeal, phar- 
yngeal, cardiac, gastric, intestinal, rectal, anal, 
hepatic, renal, vesical, vaginal, etc. 
Laryngeal crises are characterized by a sense of 
constriction of the throat, with great distress and 
choking; pharyngeal crises by dysphagia and re- 
gurgitation of food; cardiac crises by intense pre- 
cordial pain and other symptoms of angina pec- 
toris; intestinal crises by tormina and tenesmus 
and burning pain; gastric crises by intense epigas- 
tric pain, with vomiting, flatulence, eructation, 
hiccup, and consequent wasting; hepatic crises by 
symptoms of biliary colic; and renal and vesical 
crises by those of calculus or colic. 
Sensibility is often deranged in other directions. 
Most commonly its acuity is diminished-hypes- 
thesia; sometimes it is lost-anesthesia; occa- 
sionally it is heightened-hyperesthesia. Often 
sensory conductivity is retarded or delayed. Ab- 
normal sensations are frequently present-pares- 
thesias-as of numbness or tingling, formication, 
of crawling or creeping, of cold or of burning, of 
running water, etc. A not uncommon symptom 
is a feeling of constriction or a sensation as of a 
band, rope, or cord about the waist, the so-called 
girdle-sensation. Some patients cannot distin- 
guish the density of the surface on which they walk. 
In addition to alterations of common sensibility, 
changes in other varieties of sensory perception 
may be present, as of the sense of weight or of 
pressure, of position, of pain, of temperature, of 
localization. 
Another early symptom is want of muscular 
coordination-ataxia. This is most common and 
usually most pronounced in the lower extremities, 
and is responsible for the unsteadiness in walking 
and standing. When it affects the upper extremi- 
ties, it renders difficult, if at all possible, the per- 
formance of fine, delicate movements with the 
hands. In standing the patient holds his feet far 
apart, or keeps his eyes fixed upon the ground. If 
the feet are brought in juxtaposition, or if the 
guidance of the eyes is removed, or both, the pa- 
tient will sway, and he might fall if not supported. 
The gait is staggering, not unlike that of a drunken 
man, and walking in the dark or backward is 
difficult or impossible; the feet are raised high 
from the ground, thrown somewhat outward, and 
permitted to fall awkwardly. Fatigue is induced 
with undue readiness. Sometimes associated 
movements take place, a voluntary muscular act 
in one part of the body being accompanied by a 
like involuntary act in the corresponding members 
of the opposite side, or even by a movement in 
some unrelated and perhaps remote part. 
While muscular coordination suffers in varying 
degree, muscular power and muscular nutrition, 
and the response of the muscles to electric stimu- 
lation, remain practically unaltered, except when, 
late in the disease, they are affected in consequence 
of disuse. 
With the ataxia there is usually associated in- 
equality or enfeeblement or absence of the knee- 
jerks, while the cutaneous reflexes are altered in 
accordance with the changes in cutaneous sensi- 
bility. When the cervical portion of the cord is 
affected, the deep reflexes in the upper extremities 
suffer, while the knee-jerks may be preserved. 
The reaction of the pupils to light stimulation is 
generally impaired early-reflex iridoplegia-al- 
though their contractility in accommodation and 
in convergence is, as a rule, preserved throughout 
(Argyll Robertson phenomenon). Reflex dila- 
tability from stimulation of the skin of the neck 
may also be diminished or lost. The pupils are 
usually small, and may be unequal, though 
sometimes they are large. 
Paralysis of one or more ocular muscles is a com- 
mon symptom, from which not rarely recovery 
takes place; and at times there is more or less 
ophthalmoplegia, internal as well as external. In LOCOMOTOR ATAXIA 
LOCOMOTOR ATAXIA 
this way there will result strabismus, diplopia, 
ptosis, paralysis of accommodation, etc. 
Optic atrophy, of varying degree and unilateral or 
bilateral, occurs in many cases and is responsible 
for the blindness present. Impairment or loss of 
hearing or of smell or of taste is occasionally ob- 
served. Symptoms of involvement of the medul- 
lary nerves or their nuclei are not rarely noted. 
Retention of urine may result from insensibility of 
the mucous membrane of the bladder, and incon- 
tinence from the same cause, or from overflow, or 
in consequence of weakness of the sphincter vesicse. 
Cystitis may develop and lead in turn to ureteritis 
and pyelitis. The sphincter ani is generally com- 
petent, and constipation is the rule. Sexual desire 
and sexual potence are often diminished and 
sometimes entirely lost, perhaps in the train of 
satyriasis. Some cases are marked by drowsiness 
and lassitude. 
Various vasomotor, secretory, and trophic dis- 
turbances have been observed in individual cases: 
e. g., hyperemia, hyperhidrosis or anidrosis, epi- 
phora, sialorrhea, polyuria, glycosuria, diarrhea, 
ecchymoses, purpura, urticaria, herpes, ichthyosis, 
loss of nails, painless loss of teeth, bed-sores, per- 
forating ulcer of the foot, gangrene of the toes, 
spontaneous laceration of the fibers of tendons, and 
spontaneous fracture of bones. Sometimes mor- 
bid alterations take place in one or more joints- 
arthropathies-the synovial sac filling with fluid 
and the articular cartilage and adjacent bone under- 
going atrophic or hyperplastic changes. The foot 
may become thickened and deformed from altera- 
tions in joints, tendons, and muscles. Atheroma 
or arteriosclerosis not rarely attends posterior 
spinal sclerosis, and it may engender obstruction 
at the aortic orifice and incompetency of the aortic 
valves, with systolic and diastolic murmurs at the 
base of the heart on the right side. Rarely there 
are symptoms of degeneration of cerebral or spinal 
motor nerves, resulting in facial or lingual hemi- 
atrophy, paralysis of the diaphragm, and weakness 
and wasting of other muscles. In some cases, also, 
symptoms of progressive paralysis of the insane are 
superadded. Finally, apoplectiform and epilepti- 
form seizures and hemiplegia have been observed. 
Diagnosis.-The recognition of posterior spinal 
sclerosis is to be based on the lightning pains, the 
unsteadiness of gait and station, the want of coor- 
dination in the upper extremities, the diminution or 
logs of knee-jerks, the narrowing of the pupils and 
their immobility on exposure to light, the ocular 
palsies, the optic atrophy, the sensory disturbances, 
the loss of sexual desire and sexual vigor without 
psychic manifestations, muscular weakness and 
wasting, and changes in electric reactions. 
The spinal disease is to be differentiated from 
multiple neuritis by its insidious rather than acute 
onset, by the presence of visceral symptoms 
(incontinence of urine, impotence, crises), of light- 
ning pains, of girdle-sensation, of optic atrophy 
rather than neuritis, often by the absence of nerve 
tenderness, and of muscular weakness and wasting. 
Posterior spinal sclerosis may bear a close re- 
semblance to syphilis of the spinal cord, but with 
the latter the clinical picture is likely to be atyp- 
ical, while the knee-jerks may be present and even 
exaggerated, headache and papillitis are more 
commonly present, and other symptoms of syphi- 
lis may be more or less obvious. 
Cerebellar tumor may present many of the 
symptoms of posterior spinal sclerosis, but light- 
ning pains are likely to be absent, the knee-jerks 
are variable (sometimes absent, sometimes pres- 
ent), vesical symptoms are wanting, severe and 
persistent headache is a usual symptom, and 
papillitis, rather than optic atrophy, occurs. 
Treatment.-While the lesions of posterior 
spinal sclerosis are little amenable to treatment, 
much can sometimes be done by judicious manage- 
ment to mitigate the severity of the symptoms, 
and possibly to prevent the advance of the disease. 
Of primary importance is the maintenance of the 
general health, the avoidance of intercurrent dis- 
orders, and the prevention of complications. 
If there is a history of syphilis or evidence of that 
disease, with the possibility of inadequate specific 
treatment, mercury (by inunction, by hypodermic 
injection, by internal administration) or iodids 
(sodium, potassium, strontium, lithium, hydriodic 
acid) or both may be administered within the 
limits of tolerance. Either or both of these 
remedies may also be tried carefully in the absence 
of syphilis. Subcutaneous injections of testicular 
extract, prepared according to the method of 
Brown-S6quard (d'Arson val); are attended with 
marked improvement in some cases. Among 
other drugs that have been used are salts of iron, 
of zinc, of arsenic, of silver, and of gold, strychnin, 
belladonna, ergot, quinin, and phosphorus. Lan- 
cinating pains and crises may require the adminis- 
tration of antiyprin, acetanilid, phenacetin, sodium 
salicylate, codein, or even of morphin. The 
faradic brush may also be employed to relieve 
pain, as may likewise anodal application of the 
galvanic current and the static spark. A good 
deal has been claimed in this connection for the 
sinusoidal current, but the hopes raised have 
not been generally realized. Suspension of the 
body from the head, in order to exert traction 
upon the spine, has been practised at different 
times for many years, and in some cases with en- 
couraging results. Overextension of the spine by 
raising the feet of the recumbent patient over 
his head, with flexion of the trunk, has also been 
employed with the same object. Rather a more 
promising mode of procedure than any of those 
yet mentioned consists in courses of gymnastics 
calculated to improve and restore the failing 
coordination. The patient is systematically in- 
structed and trained in the most varied move- 
ments, from the simplest to the most complex, in 
this way retaining the faculties of all the nerve- 
fibers whose functions have not been lost by 
destruction of their axis-cylinders. All forms of 
exercise should, however, be kept within the 
limits of fatigue. Massage and baths are capable 
of maintaining the general nutrition, to which, 
further, a proper diet and a suitable mode of life 
should be directed. Cystitis is to be avoided, 
so far as possible, and extension of inflammation 
to the pelvis of the kidney prevented; and the LOGWOOD 
LUMBAR PUNCTURE 
formation of bed-sores is to be guarded against. 
Arthropathies may require surgical or orthopedic 
treatment. 
LOGWOOD.-See Hematoxylon. 
LORDOSIS.-See Spine (Curvature). 
LOTION.-A solution or mixture of medicinal 
agents intended for external application. It 
usually consists of some soluble astringent salt 
dissolved in water, with perhaps some glycerin or 
alcohol. A fomentation is a similar preparation 
used hot. A collyrium is an eye-wash, and 
generally contains a soluble astringent salt, dis- 
solved in rose-water or distilled water, in the 
proportion of 1 to 4 grains to the ounce. The 
only official preparation suitable for a lotion is 
lead-water. 
Black lotion or wash is prepared by adding calo- 
mel, 30 grains, to lime-water, 10 ounces, producing 
the black oxid. It is used as an application to 
syphilitic sores. Goulard's lotion contains liquor 
plumbi subacetatis. See Liquor. Yellow lotion 
or wash is prepared by adding mercuric chlorid, 
18 grains, to lime-water, 10 ounces, producing the 
yellow oxid. It is a favorite application for 
syphilitic sores. 
LOZENGES.-See Troches. 
LUCID INTERVALS.-These may occur in the 
course of a mental disease, and are defined by 
Bucknill and Tuke as not consisting in a mere 
cessation of the violent symptoms of the disorder; 
but as intervals in which the mind, having thrown 
off disease, has recovered its general habit. The 
party must be capable of forming a sound judg- 
ment of what he is doing, and his state of mind 
such that any indifferent person would think him 
capable to manage his own affairs. 
LUDWIG'S ANGINA.-An acute cellulitis, usu- 
ally of streptococcic origin, which begins in the 
region of the submaxillary gland, spreads along the 
connective tissue planes of the neck and involves 
the floor of the mouth and walls of the pharynx. 
It generally occurs during an infectious disease 
but may be due to traumatism or carious teeth. 
The neck becomes swollen and indurated and the 
mouth and throat very much inflamed. As a 
rule the onset is sudden, but the characteristic 
violent local and general symptoms may be 
preceded for a few days by localized swelling and 
tenderness of the submaxillary gland. Edema of 
the glottis may cause sudden death or fatal septic 
pneumonia; pleurisy or pericarditis may occur 
if the morbid process extends to the mediastinum. 
Treatment consists of free multiple incisions, the 
removal of necrotic tissue, cauterization with 
carbolic acid and iodin, drainage-tubes and hot 
moist dressings. Stimulants should be given free- 
ly and antistreptococcic serum injected whenever 
it can be obtained. 
LUETIN REACTION.-The luetin test is per- 
formed by injecting 0.05 c.c. of luetin intracu- 
taneously in two places on the left arm and at the 
same time 0.05 c.c. of a control suspension, con- 
sisting of the medium without any growth of 
spirochetes, at two points on the right arm. Local 
inflammation on the left arm, appearing in two to 
ten days and sometimes resulting in the formation 
of a pustule, is regarded as a positive test. The test 
is often negative in the earlier stages of syphilis. 
The various diagnostic tests for syphilis are now 
extensively employed. Microscopic search for the 
spirochete is of value in the untreated primary and 
secondary stages. The complement-fixation test 
becomes positive a few weeks after the appearance 
of the primary lesion and is generally regarded as 
indicating an active syphilitic process. The luetin 
test may be positive in latent or inactive syphilis 
when the Wassermann is negative. Further ex- 
perience with the luetin test is necessary in order to 
determine its real significance (MacNeal). 
LUMBAGO.-A form of muscular rheumatism 
affecting the muscles of the loins and their tend- 
inous attachments. It is one of the most common 
and painful forms of rheumatism. It is most 
frequently found among workmen. Its onset is 
sudden, and in very severe cases it completely in- 
capacitates the sufferer, and he may be unable even 
to turn in bed or arise from a sitting posture. As 
a rule, it is a transient affection, lasting from a 
few hours to a few days. It may be constant in 
character or occur only when the muscles are 
drawn into certain positions. Instead of being 
painful, it may take the character of a simple ache, 
which is relieved by pressure. 
Treatment.-Rest of the affected muscles is of 
the first importance. Porous plasters are believed 
to be efficacious by the public. A hypodermic in- 
jection of morphin into the affected muscles will 
relieve the severe and agonizing pain. Acupunc- 
ture, in acute cases, is a most effective treatment. 
Sterilized needles, 3 or 4 inches in length, may be 
thrust into the lumbar muscles at the seat of pain, 
and after 5 to 10 minutes withdrawn. The relief 
is often immediate. The constant current is 
sometimes beneficial. The thermocautery may 
be employed in light strokes over the affected 
muscles. Blisters may be tried in obstinate 
cases. Hot fomentations are soothing, and, at 
the outset, a Turkish bath may cut short the 
attack. In chronic cases potassium iodid may be 
used, and guaiacum and sulphur have been strongly 
recommended. Proper clothing and diet are 
needed. Large doses of nux vomica are some- 
tijnes beneficial. See Rheumatism. 
LUMBAR PUNCTURE.-Spinal (subarachnoid) 
puncture is used for anesthesia, and it has become 
a measure of marked value both for diagnosis and 
treatment. Tapping of the spinal theca may be 
practised readily and with impunity, provided per- 
fect asepsis be observed, in any interlaminal space 
between the second lumbar and the first sacral 
vertebrae. It has been found valuable in dimin- 
ishing intracranial pressure, as, for instance, in 
tuberculous meningitis. Great benefit has been 
derived from it in uremic convulsions. Lumbar 
puncture should be performed in cases of doubtful 
infantile paralysis. It is the only means available 
at present of differentiating between epidemic 
meningitis and that form of anterior poliomyelitis 
which resembles it so closely. In tetanus mag- 
nesium sulphate and tetanus serum are adminis- 
tered by injection following lumbar puncture; 
similarly antimeningococcus serum is given in LUMBRICOIDS 
LUNGS, HEMORRHAGIC INFARCTION 
epidemic cerebrospinal meningitis. See Intra- 
spinal Anesthesia, Meningitis. 
LUMBRICOIDS.-Large round-worms (Ascaris 
lumbricoides') infesting man and animals. See 
Worms (Round). 
LUNACY.-A popular name for insanity, so 
called from the traditional belief that it was in- 
fluenced by the moon. For the divisons and legal 
aspect of insanity see Insane (Laws Relative), 
Insanity. See also Delirium, Mania, Melan- 
cholia, etc. 
LUNGS, CIRRHOSIS (Chronic Interstitial Pneu- 
monia).-A chronic inflammatory disease of the 
lungs, characterized by an overgrowth of the 
connective tissue. 
Etiology.-(1) Sequel of croupous pneumonia; 
(2) fibroid phthisis; (3) fibrinous pleurisy; (4) 
bronchopneumonia; (5) inhalation of dust-pneu- 
moconiosis; if due to stone-dust-chalicosis; to 
coal-dust-anthracosis; metallic dust-siderosis. 
Pathology.-The disease is generally unilateral, 
the chest on the affected side being retracted and 
the heart displaced. The lung is greatly atrophied, 
only leaving the interstitial tissue, and is fre- 
quently so shrunken that its contour is totally 
changed. If due to tuberculosis, cavities may be 
found. Microscopically, an overgrowth of con- 
nective tissue is seen. The unaffected lung is in 
a condition of emphysema. 
Symptoms and Clinical Course.-There is a 
severe cough, accompanied by slight or profuse 
expectoration, mucopurulent in character. On 
account of the diminished size of the lung dyspnea 
is a common symptom. Fever may be absent, and 
the health remain good for many years. If due to 
tuberculosis, pulmonary hemorrhages are common. 
Physical Signs. Inspection.-There is retrac- 
tion of the chest on the affected side. The apex- 
beat is displaced. 
Palpation.-Vocal fremitus may be diminished 
or increased, depending upon involvement of the 
pleura. 
Percussion shows impaired resonance on the 
affected side, and hyperresonance on the opposite 
side. 
Auscultation.-There is heard cavernous or 
amphoric breathing at the apex, but feebler at the 
base of the lung, with large and small mucous rales. 
Diagnosis.-The affection has to be distinguished 
only from Tuberculosis (q. v.). 
Prognosis.-It is fatal in from 10 to 15 years. 
Treatment is palliative. A change of occupa- 
tion and out-of-door gymnastics may be demanded. 
See Tuberculosis. 
LUNGS, CONGESTION.-An increase in, or 
abnormal fulness of, the capillaries of the air-cells: 
active, when the result of an accelerated circulation; 
passive, when caused by an impeded outflow from 
the capillaries. For etiology, diagnosis, and 
treatment, see Hemoptysis. 
LUNGS, CONSUMPTION.-See Tuberculosis 
(Pulmonary). 
LUNGS, EDEMA.-An exudation of serum into 
the pulmonary interstitial tissue and the alveoli 
of the lungs, characterized by dyspnea, cough, and 
a frothy, blood-streaked expectoration. 
Etiology.-Pulmonary edema is the result of 
stasis, occurring when the outflow of venous blood 
in the lung meets an obstacle that cannot be 
overcome by the right ventricle, as in cardiac 
diseases in which the left ventricle fails. It also 
follows Bright's disease and alcoholic excesses, 
causing cardiac depression and lung inflammations. 
Pathologic Anatomy.-The lung tissue is swol- 
len, and does not collapse when the chest is open. 
The elasticity of the tissue has disappeared, and it 
pits upon pressure. If following congestion of 
the lungs, the color is red; if a symptom of general 
dropsy, its color is pale. On cutting into the 
edematous spots an enormous quantity of albu- 
minous fluid, sometimes clear, at other times of a 
red color, mixed more or less with blood, flows 
over the cut surface. 
Symptoms.-The preeminent symptom is dysp- 
nea, the breathing being hurried, labored, and 
rattling, all the accessory muscles of respiration 
being called into action. The sense of oppression 
and anxiety is extreme. There is also a constant, 
harassing, short cough, and the expectoration of a 
blood-streaked, frothy mucus. The action of the 
heart may be tumultuous or feeble. The face is at 
first flushed, but as the left ventricle fails, or if the 
effusion into the air-cells is sufficient to prevent the 
entrance of air, symptoms of cyanosis rapidly 
supervene, the pulse becoming feeble, the surface 
cold, the breathing shallow and hurried, the cough 
suppressed, stupor replacing the restlessness, soon 
deepening into coma. 
Percussion.-If there is no other lung-disease, 
the percussion-note is but slightly, if at all, im- 
paired. 
Auscultation.-The vesicular murmur is lost by 
the diffused subcrepitant and bubbling rales. 
Diagnosis.-Acute pneumonia in the earlier 
stages is the only condition likely to be confounded 
with edema of the lungs, but as the two diseases 
progress, the picture of pulmonary edema is so 
characteristic that it cannot be mistaken. 
Prognosis is grave, and particularly if the disease 
occurs in pneumonia, heart-disease, or Bright's 
disease. In the majority of instances it is a ter- 
minal symptom, coming on in all forms of acute 
and chronic diseases. 
Treatment.-As a rule, remedies are useless. 
The indication is to stimufate the left heart, and 
this is best done with hypodermic injections of 
strychnin sulphate, 1/24 grain, repeated every 
half hour; citrated caffein, 3 to 5 grains; spartein 
sulphate, 1 to 2 grains every hour or two, or digi- 
talin, 1/60 to 1/30 grain, repeated every hour or 
two. Two or more of these drugs may be advan- 
tageously combined. Atropin sulphate, 1/60 to 
1/100 grain, and ergot in some form are valuable 
remedies. Occasionally relief follows a free vene- 
section or the application of wet cups. Alcoholic 
stimulants are often invaluable. These means 
may be aided by counterirritation to the chest, hot 
mustard foot-baths, active saline purgatives, and 
diuretics. 
LUNGS, EXAMINATION.-See Chest (Examin- 
ation). 
LUNGS, HEMORRHAGIC INFARCTION (Pul- LUNGS, INFLAMMATION 
LUNGS, INJURIES 
monary Apoplexy).-An effusion of blood into the 
air-cells and interstitial tissue of the lungs. 
Etiology.-It is usually the result of an embolus 
which comes from the heart or from a thrombus in 
the pulmonary artery. The smaller vessel be- 
comes dilated after the embolus lodges, and from 
the effect of the blood-pressure the vessel ruptures, 
giving rise to the condition. 
Pathology.-The infarction is usually in the 
periphery of the lung and of a conic shape-the 
base toward the pleura, the apex toward the root 
of the lung. The red patches of infarction are 
clearly seen on the pleura. The infarction, when 
cut, collapses readily. 
Symptoms.-These are of an indefinite nature. 
Naturally, there is dyspnea, and if there is a val- 
vular disease of the heart with expectoration of 
dark blood, a blowing breathing at the lower lobes, 
and dulness on percussion, we may suspect pul- 
monary apoplexy. 
Treatment should be directed to the cause. The 
prime indications are to bring down the blood- 
pressure with such drugs as aconite, in doses of 3 
to 6 drops of the tincture every 3 or 4 hours, and 
to reduce the frequency of the pulse-beat by 
avoiding excitement, and the applications of ice- 
cloths over the chest for periods of 10 minutes. 
A hypodermic of 1 /4 of a grain of morphin is often 
the best thing to prevent excitement and danger 
of further hemorrhage. 
LUNGS, INFLAMMATION.-See Pneumonia, 
Tuberculosis, Pleurisy. 
LUNGS, INJURIES.-Injuries of the lungs may 
occur from mere contusion or compression of the 
thorax; they are very common as a result of frac- 
tures of the ribs; and occasionally they occur as a 
result of external wounds, penetrating from the 
outside. The wound may be superficial or deep; 
it may be punctured, incised, or lacerated, with 
or without the entrance of foreign bodies, and it 
may be so trivial that it is never diagnosed, or it 
may cause instant death. The simpler forms of 
wound heal at once by first intention, without any 
inflammation, and with very great rapidity. 
Severe contusion, owing to the extravasation into 
the air vesicles, is attended with a greater amount 
of consolidation and with rusty, blood-stained 
sputum for several days, but the dulness rarely 
extends, and there is little or no fever. If, how- 
ever, the extravasation is very great, or there is an 
external wound, so that the blood decomposes, 
intense septic pneumonia, and even gangrene, may 
follow; but there is always such an amount of 
pleural effusion, and the lung, as a rule, in these 
cases is so collapsed and compressed against the 
back of the thorax, that the physical signs are very 
obscure. 
Symptoms.-The two characteristic signs of 
wound of the lung are hemorrhage and the escape 
of air. The former may take place into the bron- 
chi, so that the sputum consists either of pure 
blood or of a frothy, bright-red mixture, which in a 
day or two becomes rusty and black; or it may 
collect in the cavity of the pleura (hemothorax), 
and gradually soak into the surrounding tissues, 
so that the skin on the loins becomes dark and 
ecchymosed; or it may escape externally, mixed 
with air, or almost pure. So with the air. In 
very rare instances, when the vesicles alone are 
torn without the pleura being injured, it may 
escape into the cellular tissue of the lung and 
make its way along the outside of the bronchi into 
the mediastinum, and so gain the root of the neck; 
or it may collect in the pleural cavity, entering at 
each expiration, until it distends the thorax to its 
utmost and compresses the lung against the back; 
or, what is far more common, without entering the 
pleura at all, it finds its way across into the cellu- 
lar tissue, and gives rise to surgical emphysema; 
or, finally, if there is a large open wound, it is 
sucked in and out of the chest at each respiration, 
mixed more or less with blood. 
Beside these, other symptoms are usually pres- 
ent. The shock of such an injury is severe and 
sometimes fatal, even when the amount of bleed- 
ing is not great; anxiety and distress are always 
marked; sometimes the dyspnea is slight, but usu- 
ally it is severe, and if the lung becomes rapidly 
collapsed, it may be extreme; there is a constant 
sense of irritation and tickling in the throat, with 
an intense desire to cough, but the deep, fixed 
pain in the chest prevents it, and if the hemorrhage 
is severe, the patient may sink rapidly into a state 
of collapse. 
Treatment is directed to control of the hemor- 
rhage by compression and the use of hemostatics, 
fixation of the chest, and general supportive 
measures. See Hemoptysis. 
Pneumatocele, hernia, or prolapse of the lung 
is an occasional but rare complication of injuries 
of the thorax. It may be either immediate or 
secondary. In the former case there is generally 
a wound of some extent in the parietes, and the 
lung is forced out through it by a violent effort at 
expiration when the glottis is closed. It may be 
injured itself or it may not, but as soon as it is 
squeezed out through the rent, it expands so that 
it cannot return, and rapidly becomes congested. 
In extreme cases it may be strangulated. If seen 
shortly after the accident, an attempt may be 
made to return the protrusion, and, if necessary, 
the wound may be slightly enlarged for the pur- 
pose; but if some time has elapsed, and the tissue 
is very much congested, it is better left where it is 
to slough off and granulate over; or its separation 
may be assisted by ligature or actual cautery. A 
very few instances are recorded in which, owing to 
extensive injury of the thorax, an immediate pro- 
lapse of the lung has occurred without an external 
wound. 
• The consecutive variety may not make its appear- 
ance until some considerable time after the receipt 
of the injury, and if there has been a wound, it 
must have healed first. It forms a soft, circum- 
scribed tumor, projecting through the wall of the 
thorax under the skin, swelling out on expiration 
and shrinking on inspiration. On coughing 
there is a distinct impulse; if it is pressed upon, 
it collapses readily, with a feeling of soft crepita- 
tion, and the margins of the opening can be plainly 
felt. It is resonant on percussion, and the respira- 
tory murmur is loud and coarse in comparison. LUNGS, SURGERY 
LUNGS, SURGERY 
In some cases it is the result of extensive rupture 
of the intercostal muscles; in others, where its 
formation is very gradual, it is probably due to 
chronic inflammation weakening the walls of the 
thorax at one spot, and allowing the lung slowly 
to force its way through. The only treatment 
required is a belt or truss, according to the size and 
situation of the protrusion, to restrain it and pro- 
tect it from injury. 
For further discussion of injuries of the lung, see 
Chest (Injuries), Pleura, Pleurisy, Pneumonia. 
LUNGS, SURGERY.-The dangers of intrathor- 
acic surgery have been lessened by the ingenious 
methods devised for preventing collapse of the 
lung when the pleura is widely opened. Both 
positive and negative pressure are employed. 
The former prevents collapse of the lung by dis- 
tending it from within, the latter by making suc- 
tion upon its exposed surface. When positive 
pressure methods were first introduced, and for 
sometime thereafter, they were assailed as being 
dangerous, but evidence based upon continued 
animal experiments and also upon the results of 
their application to the human subject, show that 
the objections were theoretical rather than prac- 
tical. Kuttner, Dreyer, Robinson and others 
have demonstrated that the air exchange in the 
trachea, the venous pressure, the aortic and pul- 
monary pressure, and the expansion of the thorax 
are the same under positive pressure as they are 
under negative pressure. 
an air tight cabinet in which the surgeon operates. 
The patient's head projects outside the cabinet 
and a tight fitting rubber collar is placed around 
his neck. Negative pressure is obtained by 
means of an electric suction air-pump. As the 
bronchioles are subjected to ordinary atmospheric 
pressure at the time that the thorax is exposed to 
negative pressure, collapse of the lung does not 
occur. It is interesting to note that an increased 
number of successful intrathoracic operations are be- 
ing done in the clinics where this apparatus is in use. 
And see Intratracheal Insufflation of Ether. 
Incision of the lung (pneumotomy) has been 
practised in cases of gangrenous cavities, abscesses 
caused by the extension of suppuration from 
other parts into the lung, abscesses connected 
with foreign bodies, bronchiectatic cavities, pro- 
vided they are single (multiple ones can hardly 
receive much relief this way), and tubercular cavi- 
ties, if there is only one, and the cough is very 
harassing. In one or two cases a similar operation 
has been practised for hydatid disease, and a few 
instances are recorded in which tumors have been 
removed from the lung. The localization of the 
disease and the treatment of the pleura are the 
chief difficulties. No incision may be made until 
the existence and accessibility of the cavity have 
been proved by puncture, and even then the great- 
est care is required, for the lung, unless it is con- 
solidated by inflammation, is so yielding that a 
thick-walled sac can easily be pushed to one side. 
As a rule, cavities should not be approached from 
behind, for the large vessels run for the most part 
along the posterior surface of the bronchi. The 
size of a cavity cannot be estimated from the 
amount of fluid that is coughed up; according to 
Godlee, upward of a pint may come within 24 
hours from a space that would not hold so much as 
44 c.c. If a cavity is found, the lung tissue should 
be incised, and explored as far as possible with 
the finger, part of a rib being removed if necessary, 
and a large drainage-tube inserted. The shape is 
always very irregular, and it must be a long time 
before the sloughs have separated, and cicatriza- 
tion can procure its obliteration. 
The treatment of the pleura presents unusual 
difficulties. There can be no doubt that it is not 
advisable to incise a putrid cavity in the lung 
unless the pleural surfaces are adherent. If 
there is localized gangrene, and if it has already 
lasted for some time, the danger is not so great; 
adhesions are usually present under these condi- 
tions, and the lung is so consolidated by inflam- 
mation that it is in but slight danger of collapsing; 
but in acute cases and in bronchiectasis it is impos- 
sible to be certain. An attempt may be made to 
find out by ascertaining the mobility of the lung; 
if a needle is driven through an intercostal space 
into the pulmonary tissue, it will show to a certain 
extent by its movement whether the lung is fixed 
or not, but it is very easy to place too much reli- 
ance upon this. In some instances it may be 
possible to suture the two surfaces together and 
wait for a week, or to procure adhesions by means 
of the cautery applied to the intercostal muscles, 
but often it is impossible to wait so long, and even 
a. Opening of pipe connecting with suction pump; b, 
valve to let in air, and regulate the negative air pressure. 
-(Bryant and Buck's American System of Surgery.) 
Sauerbruch's Pneumatic Cabinet. 
With regard to the apparatus employed, that 
for positive pressure is simpler than that for nega- 
tive. Robinson and Leland state that the 
requirements of any positive pressure apparatus 
are a supply of compressed air; an anesthetizing 
segment; a device for introducing air and ether 
into the respiratory tract; a means of varying the 
resistance of the exhaled air. It would seem that 
all of these requirements are not perfectly met 
by any single apparatus thus far devised, but they 
are present in sufficient degree to make the ingeni- 
ous instruments of great practical value. 
Sauerbruch's apparatus for negative pressure is LUPINOSIS 
LUPUS ERYTHEMATOSUS 
then the adhesions are so soft and delicate that the 
greatest care must be taken not to break them 
down (Moullin). 
Excision of lung tissue (pneumonectomy) has 
been suggested to remove diseased portions. To 
remove the apex, the third or fourth rib is excised 
without opening the pleura until it is removed. The 
lung is then grasped and drawn into the pleural 
opening, which it plugs, and relieves the distress 
occasioned by allowing the air to enter. The 
portion of lung to be removed is ligated en masse 
and then cut away, the stump being seared with 
the cautery. The wound in the pleura is closed 
and sealed with collodion. The ligature must be 
firmly applied and asepsis must be rigid (Pyle). 
The results of the operation are not yet definitely 
determined. 
LUPINOSIS (Lathyrism, Chick-pea Disease).- 
An affection due to prolonged use of meal made 
from the chick-pea (or vetches) which is mixed with 
barley and wheat. It is observed in India, France, 
Italy and Algiers. The symptoms are gastro- 
intestinal derangement, pain accompanied by 
weakness and tremor followed by spastic paraly- 
sis of the legs with exaggerated reflexes. Treat- 
ment consists in removing the cause and relieving 
the symptoms. 
LUPULIN.-The yellow, resinous powder of 
hops, composed mainly of dried glands from the 
strobiles of the plant; it is the lupulinum of the 
U. S. P. Its oleoresin is official. Dose, 5 to 15 
grains. In nervous irritability lupulin may be used 
as a calmative and hypnotic. In irritable bladder, 
in alcoholism, and as an anaphrodisiac in chordee, 
gonorrhea, spermatorrhea, and other affections of 
the genitourinary organs, it is serviceable. See 
Hops. 
In dysmenorrhea: 
1$. Lupulin, 3 j 
Confection of rose, q. s. 
Make into 20 pills. One pill 3 times a day. 
LUPUS ERYTHEMATOSUS.-A cutaneous new 
growth characterized by well-defined reddish 
patches covered with yellowish or grayish adher- 
ent scales. 
Symptoms.-The disease begins as one or more 
rounded or oval, pinhead-sized to pea-sized erythe- 
matous spots, which increase in size, either by per- 
ipheral extension or by coalescence of neighboring 
lesions. When fully developed, the disease ap- 
pears as one or more sharply marginated, reddish 
or violaceous patches, varying in size from a small 
coin to the palm of the hand. The surface is 
covered by grayish or yellowish scales, firmly 
adherent to and dipping down into the patulous 
and distended openings of the sebaceous glands. 
The border of the patch is somewhat elevated, 
while the central portion is slightly depressed. 
Whitish atrophic scarring is usually present, and is 
characteristic of the disease. There is more or less 
infiltration and thickening. The subjective symp- 
toms consist of moderate itching and burning. 
The region most frequently affected is the face, 
particularly the cheeks and nose. The lips and, 
more rarely, the buccal mucous membrane may 
also be attacked. 
The disease pursues a slow course, lasting 
months, and at times years. Occasionally involu- 
tion of the patches occurs, with or without the 
persistence of scars. 
Etiology.-The cause is obscure. Erythemat- 
ous lupus is essentially a disease of adult life. It 
is more common in women than in men. Dis- 
orders of the sebaceous glands act as predisposing 
causes. 
Diagnosis.-Lupus erythematosus may be dis- 
tinguished from lupus vulgaris as follows: 
Lupus Erythematosus. 
1. Develops in adult life. 
2. Disease is superficial. 
3. The lesions well-de- 
fined, scaly patches. 
4. Sebaceous ducts patu- 
lous or distended. 
5. Ulceration never oc- 
curs. 
Lupus Vulgaris. 
1. Develops in child- 
hood or youth. 
2. Disease is deep- 
seated. 
3. The lesions discrete 
papules and tuber- 
cles. 
4. Sebaceous system 
not involved. 
5. Ulceration with scar- 
ring nearly always 
present. 
Prognosis.-Favorable as to ultimate cure, but 
guarded as to duration of disease. 
Treatment.-But little reliance is to be placed 
upon internal treatment, although such drugs as 
iodin, arsenic, cod-liver oil, etc., are occasionally of 
value. 
The local treatment consists of the use of seda- 
tive or stimulating applications, caustics, or surgical 
manipulation, according to the nature of the case. 
Inasmuch as a certain number of cases recover 
spontaneously, with little or no scarring, the milder 
remedies should always be given a fair trial before 
proceeding to the use of caustics and the like. 
Most cases do well under stimulating applica- 
tions. An admirable method is vigorously to rub 
into the part, every day or every other day, sapo 
viridis or the tincture of green soap. This may 
be followed by a soothing ointment. Plasters are 
frequently of great value. Those most employed 
are the ordinary mercurial plaster and a 10 to 20 
percent salicylic acid plaster. 
When these remedies fail, and when the affection 
is severe and of long standing, one may cautiously 
resort to the use of such caustics as pure carbolic 
or trichloracetic acid, liquor potassse, nitrate of 
silver, etc. Scarification and superficial curetting 
are often followed by good results. Sulphur, either 
in ointment (1 to 2 drams of precipitated sulphur 
to 1 ounce) or lotion, is a most efficient remedy. 
A combination of sulphur and tar makes a use- 
ful formula: 
I}. Precipitated sulphur, 3 j 
Oil of cade, 3 j 
Zinc oxid ointment, 3 j. 
Apply twice a day. 
Crocker speaks well of the use of collodion, either 
alone or with salicylic acid (10 to 30 grains to 1 
ounce) incorporated in it. LUPUS VULGARIS 
LUPUS VULGARIS 
Liquid air or, preferably, carbon dioxid snow 
has been used with excellent results. 
LUPUS VULGARIS.-A tuberculous cellular 
new growth, characterized by reddish or brownish 
patches consisting of papules, nodules, and flat 
infiltrations, usually terminating in ulceration and 
scarring. 
Symptoms.-The disease commonly begins as 
numerous pinpoint-sized to pinhead-sized, grouped 
or disseminated, reddish, yellowish, or brownish 
flat papules. They are softer than the surrounding 
skin, in which they appear to be embedded. Hut- 
chinson has likened their appearance to "apple 
jelly." 
These papules develop later into pea-sized or 
larger tubercles or nodules, which ultimately be- 
come aggregated in variously sized and shaped 
patches covered with imperfectly formed epider- 
mis. After a variable duration the nodules coa- 
lesce, chiefly by individual extension, forming dull 
red, raised, soft patches. 
The lupus nodules or patches may remain station- 
ary for some time, but sooner or later undergo 
retrogressive change. The lesions may disappear 
by absorption, leaving a somewhat scarred, scaly, 
and atrophic skin (lupus exfoliativus}, or, as is the 
more usual course, by ulceration, with resulting 
crusts and cicatrices (lupus exedens, lupus ex- 
ulcer ans). At times exuberant granulations spring 
up upon the borders of the ulcer (lupus hypertro- 
phicus'), or there may develop even papillomatous 
outgrowths (lupus papillomatosus). 
The most frequent seat of lupus is upon the face, 
particularly the nose, cheeks, and ears. The trunk 
and extremities may also be involved. Besides 
the skin, lupus occasionally attacks the mucous 
membrane and cartilage of the nose, mouth, 
pharynx, larynx, or ears. 
Subjective symptoms are, as a rule, wanting, 
although there may be slight pain. 
The course of the disease is eminently chronic, 
the affection persisting for years, and frequently a 
lifetime. 
Etiology.-The vast majority of cases begin 
before the age of 20, and many before the age of 10. 
The disease, however, is never congenital. 
Lupus vulgaris is due to the invasion of the skin 
by the tubercle bacillus. 
Pathology.-A section of lupus tissue shows, 
under the microscope, sharply circumscribed nests 
of cell-infiltration in the deeper layers of the corium. 
Epithelioid cells are present in varying numbers, 
and giant cells in abundance. Tubercle bacilli are 
few, and only discoverable by examination of 
many sections. When ulceration occurs, the 
centers of the nodules undergo coagulation necrosis 
and fatty degeneration. 
Diagnosis.-The diseases most likely to be con- 
founded with lupus vulgaris are the tubercular 
syphiloderm, lupus erythematosus, and epithe- 
lioma.. 
2. Course slow. 
3. History, perhaps, of 
scrofulous heredit- 
ary tendency. 
4. Concomitant signs of 
tuberculous diathe- 
sis. 
5. Nodules soft. 
6. Ulcers are compara- 
tively superficial, 
with irregular, un- 
dermined edges; 
discharge slight; 
crusts scant and 
reddish-brown. 
7. Scars yellowish, 
shrunken, and 
hard. 
8. Refractory to all but 
destructive meas- 
ures. 
Lupus Vulgaris. 
1. Develops usually be- 
fore puberty. 
2. Course extremely 
slow. 
3. Little or no pain. 
4. Ulcers multiple and 
superficial. 
5. Edges and base soft. 
2. Course rapid. 
3. History of infection. 
4. Concomitant signs of 
syphilis. 
5. Nodules hard. 
6. Ulcers are deep, with 
sharp-cut edges; 
discharge copious; 
crusts bulky and 
greenish. 
7. Scars whitish, soft, 
and smooth. 
8. Rapid healing under 
the iodids and mer- 
cury. 
Epithelioma. 
1. Develops in middle 
and advanced life. 
2. Course more rapid. 
3. Usually painful. 
4. Ulcers single and 
deep. 
5. Edges and base hard; 
characteristic pear- 
ly border. 
Prognosis.-The disease runs a decidedly chronic 
course. The prognosis depends upon the age of 
the patient and the form, extent, and duration of 
the disease. Occurring in small, circumscribed 
patches, the prognosis is favorable. 
Treatment.-General hygienic measures, such 
as nutritious diet, fresh air, exercise, etc., should 
receive attention. In many cases the administra- 
tion of such remedies as cod-liver oil, iodid of iron, 
etc., is indicated, although no direct curative in- 
fluence is to be expected from their use. Thyroid 
extract and tuberculin have been used in some 
cases with encouraging results. Their curative 
value, however, is at the present time still conjec- 
tural. 
Local treatment has for its object the extirpation 
of the lupus tissue with as little resultant scarring 
as possible. Before resorting to chemic caustics 
or surgical interference, it is well in some cases to 
employ milder measures. In hyperemic cases the 
condition is sometimes improved by the continued 
application of calamin lotion. Mercurial plaster 
occasionally exerts a beneficent influence on the 
disease. A salicylic acid (20 percent), creosote 
(40 percent), or resorcin plaster has been used with 
good results. Most cases, however, require more 
heroic treatment. The solid stick of silver nitrate 
is useful in the treatment of small discrete lesions. 
It is bored into the tissue until the nodule is de- 
stroyed. Every few days new lesions are attacked. 
Pyrogallic acid is a slow but practically painless 
caustic. It may be used in ointment or as a paint. 
Brocq advises the following: 
Lupus Vulgaris. 
1. Develops usually be- 
fore the age of pu- 
berty. 
Tubercular Syphilo- 
DERM. 
1. Develops after the 
age of puberty. LYCETOL 
LYMPHADENOMA 
I|. Pyrogallic acid, 
Salicylic acid, 
each, gr. 1 
and antispasmodic, and was used in rheumatism, 
epilepsy, and pulmonary and renal disorders. 
The powder is now employed quite extensively 
in pharmacy to facilitate the rolling of a pill-mass 
and to prevent adhesion of pills to each other. 
It makes an excellent absorbent and protective 
powder when dusted over an excoriated surface, 
as seen between the thighs of infants. 
LYMPHADENOMA (Hodgkin's Disease; Lym- 
phatic Anemia, Lymphadenosis Pseudoleukemia; 
Malignant Lymphoma.)-A form of anemia char- 
acterized by a hyperplasia of the lymphatic glands, 
usually a hypertrophic condition of the spleen, and 
without leukocytosis. 
Etiology.-It generally occurs in people under 
25 years of age, the majority of cases collected by 
Gowers being males. The exciting cause is not 
known. It has been attributed to constant ir- 
ritation of the skin, to decayed teeth, to nasal 
catarrh-these conditions exciting a local glandu- 
lar swelling which becomes general. 
Pathology.-A hyperplasia of the lymph- 
glands is always present. A hypertrophic condi- 
tion of the spleen is found in the majority of cases. 
The cervical lymph-glands are usually the first to 
enlarge, and soon involve the whole chain of glands. 
The axillary and inguinal glands are next affected. 
The marrow of the long bones is said to be con- 
verted into the soft lymphoid material. The 
liver is often enlarged, and is the seat of lymphoid 
tumors. 
Symptoms and Course.-In the early stages the 
blood is either normal or there is a slight degree of 
anemia. Later there is a leukocytosis, the adult 
cells (polymorphonuclear leukocytes) alone being 
greatly increased. Myelocytes are occasionally 
found. With the advance of the destruction of 
red cells there is a corresponding diminution in the 
percentage of hemoglobin. The enlargement of 
the superficial glands of the neck usually marks 
the onset. They may be small and movable at 
first, but later involve the superstructures, and 
become hard and painful. They rarely suppurate. 
The liver and spleen are usually found enlarged. 
With the increase in the size of the lymph-glands 
there is a corresponding impoverishment of the 
blood. Dyspnea may be common. If there is 
enlargement of the abdominal lymphatics, pres- 
sure-symptoms arise, and there will be edema 
of the lower extremities. In the beginning there 
is slight fever, with a variation in the daily tem- 
perature, that in the evening being higher. 
Diagnosis.-Syphilis may give rise to enlarge- 
ment of the lymphatics, but the history will clear 
up the doubtful nature and an examination of the 
blood will confirm it. 
Tuberculous glands usually occur in younger per- 
sons, and generally suppurate. In Hodgkin's 
disease suppuration is rare. In scrofulous (tuber- 
culous) glands ordinarily only one chain of glands 
is involved, and usually these are the submaxillary, 
while in Hodgkin's disease the anterior and poste- 
rior cervical glands are generally first affected. 
The tuberculin test should be employed. 
In tuberculous adenitis the liver and spleen are 
not enlarged to so great a degree as in pseudoleu- 
Paint on the part every day until a slough is 
produced. 
Arsenic trioxid is a rapid caustic, exerting a 
selective action upon diseased tissue. It is, how- 
ever, very painful, and can only be used over small 
areas, on account of the danger of absorption. 
J|. Arsenic trioxid, gr. xx 
Powdered acacia, 5 j 
Water, q. s. 
Spread on lint and apply for 24 hours. 
Then poultice until slough comes away. 
Zinc chlorid is an efficient caustic, not so painful 
as arsenic. It does not, however, select diseased 
tissue. 
1$. Zinc chlorid, o xvj 
Powdered opium, 5 jss 
Hydrochloric acid, 5 vj 
Boiling water, § xx. 
(Middlesex Hospital formula.) 
To 1 ounce of the solution add 2 drams of 
wheaten flour. Spread the paste upon lint 
and apply for 24 hours. 
Curetting is an extremely valuable procedure. 
It is often supplemented by the use of a caustic or 
the application of the Paquelin cautery. 
Scarification is a most useful measure, particu- 
larly in diffuse superficial patches. Numerous 
parallel incisions, crossed at right angles by others, 
are made through the skin by means of a sharp 
scalpel or scarifier. This is often advantageously 
followed by the application of an iodoform oint- 
ment or a bichlorid lotion. 
The galvanocautery and the Paquelin cautery find 
a distinct field of usefulness in the treatment of 
certain forms of this disease. 
Direct exposure to sunlight for 4 to 5 hours a day 
for months is reported to be effective. Remark- 
ably good results have been attained by the use 
of the X-rays. 
LYCETOL.-A tartrate of dimethyl diethylene- 
diamin (dimethyl piperazin). It is said to be a 
reliable diuretic and uric acid solvent, free from 
untoward effects on the stomach, even though its 
use be long-continued. Dose, 15 to 30 grains 
daily in carbonated water or in lemonade. 
LYCOPODIUM.-A very mobile, pale yellow, 
fine powder, consisting of the spores of the club- 
moss (Lycopodium clavatum) and of other species 
of Lycopodium. Lycopodium is odorless, taste- 
less, floats on water, which does not wet it, and 
burns quickly when thrown on a flame. It should 
be free from pine-pollen, starch, sand, and other 
impurities, which are detected by means of the 
microscope the lycopodium spores being about 
1/800 of an inch in diameter, four-sided, and 
reticulated, with short projections on the edges. 
They contain about 47 percent of a bland, fixed oil. 
The plant was formerly considered to be diuretic 
Collodion, o j. LYMPHATICS, DISEASES 
LYMPHATICS, DISEASES 
kemia. Lastly, as the disease advances, in 
pseudoleukemia there is a corresponding degree of 
anemia, as shown by the blood examination. 
Leukocythemia is differentiated by its character- 
istic leukocytosis. 
Carcinoma of lymphatic glands is generally 
secondary to cancer in another region. Lympho- 
sarcoma tends to invade neighboring tissues. 
Diagnosis in malignant disease is confirmed by 
microscopic examination of a section of the tumor. 
Prognosis.-Recovery is rare. Death usually 
occurs before the end of the third year of the 
disease. 
Treatment.-If the glands are superficial, 
they should be excised, to prevent the disease 
spreading. Neighboring glands should also be 
removed. Late in the course an operation does 
no good. Of medicines, arsenic seems the most 
effective. Any of the prescriptions recom- 
mended under Anemia (q. v.) may be given. The 
injection of arsenic into the involved tissue is said 
to be especially valuable. Bone-marrow, sodium 
cacodylate or atoxyl may be used. With the use 
of medicine it will also be beneficial to surround 
the patient with the best possible hygienic condi- 
tions or recommend a change of climate. Phos- 
phorus, in doses of 1/100 of a grain after meals, 
may also be given. lodid of potassium in 10-grain 
doses, cod liver oil, iron, strychnin, inunctions of 
iodin (1 percent) are recommended. Improve- 
ment is reported as resulting from X-ray treat- 
ment. Local applications have never proved of 
much benefit. 
LYMPHATICS, DISEASES. Lymphangitis, or 
inflammation of the lymphatic vessels, is generally 
associated with more or less inflammation of the 
lymphatic glands. 
Etiology.-The most common cause is the ab- 
sorption of septic or of infective products from a 
wound, which, however, is often very trivial, 
such as a simple scratch, abrasion, sting, or punc- 
ture; more rarely, the inflammation may follow 
upon mere irritation of the skin, as a chafe of the 
heel, excessive friction, or sunburn. 
Pathology.-The walls of the lymphatics become 
infiltrated with cells, swollen, and softened; while 
the endothelium is shed and the lymph contained 
in the vessels often undergoes coagulation. The 
inflammation spreads to the surrounding tissues, 
but seldom higher in the course of the lymphatics 
than the first set of glands, which also become 
swollen and infiltrated and arrest the further 
absorption of the septic products. It may termi- 
nate in resolution, or in suppuration in and around 
the glands or, more rarely, around the lymphatics 
themselves. Sometimes the septic products appear 
to escape the glands, and general blood-poisoning 
ensues. 
Symptoms.-In severe cases lymphangitis gener- 
ally begins with a chill or rigor, followed by high 
temperature and fever, and perhaps vomiting and 
diarrhea. Red lines, when the superficial lymphat- 
ics are affected, are seen running from the wound 
to the nearest lymphatic glands, with here and there 
erysipelatous patches of redness. There are gen- 
erally pain and tenderness, especially in the region 
of the swollen glands, and swelling and edema, 
sometimes of the whole limb. It may be differ- 
entiated from phlebitis by the redness being super- 
ficial and in the course of the lymphatics, not in 
the course of the veins, by the absence of the cord- 
like and knotty feel of plugged veins, and by the 
presence of glandular enlargement; from erysipelas 
by the redness having no defined margin, and 
generally running in lines. 
The treatment consists in attending to any 
wound or abrasion, allaying other sources of 
irritation that may be present, and placing the 
inflamed part at rest in an elevated position. 
Hot fomentations of poultices, or glycerin and 
belladonna, may be applied, and abscesses 
should be opened as soon as they form. If any 
swelling is left, pressure, or ammoniac and mercury 
plaster, may be used to disperse it. 
Lymphatic varix, or lymphangiectasis, is very 
rare. It is attended by a condition of elephan- 
tiasis of the parts where the lymphatics are 
blocked. When the superficial vessels are affected, 
" the varix first appears in the form of small eleva- 
tions, giving the skin an appearance which has 
been compared to the rind of an orange. It sub- 
sequently takes the form of little vesicles, covered 
with a thin layer of dermis" (Erichsen). At times 
the dilated lymphatics form distinct tumors 
(lymphangiomata). 
Treatment.-Slight elastic pressure and protec- 
tion from injury or irritation. 
Lymphatic fistula, or lymphorrhea, though ex- 
ceedingly rare, is a condition sometimes met, and 
more especially in the groin, scrotum, or labium. 
It is said to be due to a wound of a lymphatic or 
to the giving way of a varicose lymphatic, but the 
cause is not clearly understood. 
Lymphadenitis, or inflammation of the lymph- 
atic glands, may be acute, subacute, or chronic. 
Acute or subacute inflammation of lymphatic 
glands is nearly always secondary to inflammation 
of the parts from which the afferent lymphatics 
proceed. Indeed, in most inflammations there is 
some tenderness of the neighboring glands. The 
lymphatic vessels themselves often escape, 
although the glands may become extensively in- 
volved, and even suppurate. The inflammation, 
however, rarely proceeds further in the course of 
the lymphatics than the first series of lymphatic 
glands, although it often spreads to the surround- 
ing tissues (perilymphadenitis). The changes in 
the inflamed gland are like those of other inflamma- 
tions. The whole gland is enlarged, the vessels 
dilated, and the lymph sinuses crowded ■with cells. 
Microorganisms similar to those found in the 
inflammatory lesion, giving rise to the lymph- 
adenitis, have been discovered in the glands. 
The symptoms are tenderness, heat, pain, and 
swelling, followed by redness of the skin and edema. 
The gland, at first movable, becomes fixed, and if 
the process runs on to suppuration, the usual 
signs of an abscess ensue. Familiar examples of 
lymphadenitis are seen in the bubo of gonorrhea, 
in the tender glands of erysipelas, and in the sup- 
purating bubo of soft chancre. In from 2 to 3 
weeks after the appearance of the chancroid, in LYMPHATICS, DISEASES 
LYSSA 
the proportion of about 1 case in 4, a single lymph- 
atic gland in the groin becomes swollen, painful, 
and tender; the overlying skin becomes red, ede- 
matous, hot, swollen, and inflamed; a soft spot 
appears upon the swelling, and after a little while 
there is decided fluctuation and an abscess is 
formed in the gland. 
The treatment consists in subduing the inflamma- 
tion of the part from which the lymphatics pro- 
ceed, painting the glands with glycerin and bella- 
donna, applying a hot poultice, and, if suppuration 
has occurred, in making a free incision. Some 
surgeons dissect out the glands if suppuration 
threatens. As soon as a bubo begins to swell and 
becomes tender, it is advised to charge a syringe 
with the 1 : 500 solution of corrosive sublimate 
or with a 3 percent solution of carbolic acid and to 
inject a few drops into the gland, repeating this in 
different portions of the diseased structure until 15 
or 20 drops of the solution have been introduced. 
If this does not arrest the formation of pus, it will 
be necessary to wait, and when the pus is formed 
lay the abscess freely open. 
Chronic lymphadenitis is very common in strum- 
ous children, especially in the neck. The affec- 
tion of the glands can frequently be traced to 
some exciting cause, as the irritation of pediculi on 
the head, eczematous affections about the mouth, 
enlarged' tonsils, or carious teeth. It also occurs 
as a result of chronic affection, especially of 
tuberculosis and syphilis. The glands slowly 
enlarge and become infiltrated with small round- 
cells; while in the tubercular cases nonvascular 
areas containing giant cells, lymphoid corpuscles, 
and tubercle bacilli are found. The enlargement 
may subside, or the inflammatory products may 
caseate, and suppuration occur in or in and around 
the gland; at times the caseous mass may dry up 
and become cretaceous, or atrophy or fibroid 
thickening may ensue. In rare instances, it is 
said, the tubercle may become disseminated, 
leading to general tuberculosis. 
Symptoms.-The glands, when those of the neck 
(the most common situation) are affected, enlarge 
on one or both sides of the neck, but without pain. 
They are at first distinct and movable, but later 
often coalesce and become adherent to the sur- 
rounding parts. After a time they may soften 
and break down; the skin then becomes adherent 
and red, gives way, and a curdy pus is exuded. 
After the abscess has been opened, a portion of 
the broken-down gland may be seen in the floor 
of the ulcer, the edges of which are bluish-pink 
and undermined. The ulcers are very indolent, 
and, when finally healed, leave characteristic 
raised, puckered, pinkish-white scars. Concomi- 
tant signs of struma or tubercle are frequently 
present. 
Treatment.-Any source of irritation, such as 
pediculi, carious teeth, etc., should be sought and 
removed; and if the patient is syphilitic or tuber- 
culous, specific treatment is indicated. If suppura- 
tion threatens, the glands should be removed. If 
an abscess has already formed, it should be opened 
early to prevent scarring. This may be done by 
a small incision, after which the capsule of the 
gland may be cleared out by a Volkmann's spoon. 
Should an indolent ulcer or sinus remain, as often 
happens if the abscess is allowed to burst spon- 
taneously, it should also be scraped with a Volk- 
mann's spoon and its edges destroyed by silver 
nitrate or potassium hydroxid or, better, excised. 
With good drainage established, Bier's suction 
glasses may be efficient. In some cases inj ection 
of iodoform emulsion or iodoform packing may be 
advantageous. If streptococci or staphylococci 
are found in the pus, autogenous vaccines may 
be of decided value. 
Treatment of Tuberculous Glands.-The X-rays 
have been used with success. Bier's constriction 
hyperemia may be markedly beneficial. (The 
elastic bandage may be used at first, then if an 
abscess forms, after incising and evacuating, 
suction should be applied.) Tuberculin injections, 
the results of which seem very encouraging, should 
be tried. (See Tuberculosis.) If no improve- 
ment results in three months the bovine strain 
should be used. In adults and those with a family 
history of the disease the human bacillus is gener- 
ally the cause, but in children the bovine type is 
usually found, due to milk infection. According 
to Ritchie, to the bovine type is generally due 
glandular, skin, and eye tuberculosis; to the 
human, bone and lung varieties. Another valu- 
able remedy is guaiacol in the form of inunctions. 
LYMPHATISM.-See Status Lymphaticus. 
LYSIDIN (Methylglyoxalidin).-Lysidin is pre- 
pared by the interaction of sodium acetate and 
ethylendiamin hydrochlorid. It is a bright-red 
crystalline mass, very hygroscopic, and charac- 
terized by a peculiar mouse-like odor. It is sold 
in a 50 percent solution. Lysidin is recommended 
as a solvent for uric acid deposits, being given in 
doses of 1/2 to 2 1/2 drams of the 50 percent 
alkaline solution dissolved in an excess of car- 
bonated water. It is claimed that lysidin possesses 
five times the power of piperazin. 
LYSOL.-An antiseptic and disinfectant saponi- 
fied product of coal-tar, chiefly composed of 
cresols, occurring as a clear brown, oily liquid, 
readily miscible with water, and forming clear 
solutions with glycerin, alcohol, chloroform, and 
various other fluids. It is generally employed in a 
1 percent solution, and only as a local application. 
It is said to be superior to carbolic acid, creolin, 
and other analogous coal-tar products as a germi- 
cide, but it has no advantage over other antiseptics 
of established reputation, and is only efficient in 
solutions of sufficient strength to be irritating or 
caustic. It is useful to arrest epidemics or in 
prophylaxis, and is particularly serviceable in dis- 
infection of privies, premises, ships, and stables, 
being readily soluble, active, and cheap. A solu- 
tion of 1 :1000 is said to destroy streptococci in 
15 minutes. 
LYSSA.-See Hydrophobia. MACROGLOSSIA 
MAGNET 
M 
MACROGLOSSIA.-Hypertrophic development 
of the tongue, a condition seen in cretins, in whom 
it is probably due to lymphangioma. See Tongue. 
MADELUNG'S DEFORMITY.-This is a pro- 
gressive forward (rarely backward) subluxation of 
the radiocarpal joint, due to relaxation of the liga- 
ments or to disturbance in the growth of the radial 
epiphysis. Eighty per cent, of the cases occur in 
girls during adolescence. The lower end of the ulnais 
prominent, the radius often curved, and the hand usu- 
ally adducted but occasionally abducted. Exten- 
sion and sometimes flexion of the wrist are impaired. 
The treatment in the early stages is a retentive ap- 
paratus, e. g., a leather cuff. At a later period ten- 
otomy, reduction through an incision, or cuneiform 
osteotomy of the radius may be indicated (Stewart). 
MADURA FOOT.-See Mycetoma. 
MAGNESIUM.-Mg; atomic weight 24.3; quan- 
tivalence u; specific gravity 1.75. One of the 
metals of the alkaline earths, widely distributed in 
inorganic nature and forming also a constituent 
of animal and vegetable tissues. The physiologic 
effects of its salts are antacid and laxative. 
Therapeutics.-Magnesia and magnesium car- 
bonate are used as antacids and laxatives, in acid- 
ity, sick headache, flatulent colic, etc., and as 
antidotes in poisoning by acids, arsenic, phosphor- 
us, and mercuric and cupric salts. The citrate is 
an agreeable laxative, cooling and acceptable to 
the stomach. The sulphate (Epsom salt) is one 
of the most efficient of the saline cathartics, and 
has a wide field of application. In acute inflam- 
matory conditions, renal and cardiac dropsy, 
ascites from obstruction of the portal circulation, 
increased blood-pressure within the cranium, in- 
testinal obstruction without acute inflammation, the 
constipation of lead-poisoning, and habitual consti- 
pation from deficiency of the intestinal secretions, 
this agent will be found to be exceedingly service- 
able. Acute dysentery is well treated by magne- 
sium sulphate combined with diluted sulphuric acid, 
and followed by opium and starch enemata. Bleed- 
ing from hemorrhoids and uterine hemorrhage are 
often relieved by the same combination when other 
agents fail. In acne vulgaris and other obstinate 
eruptions due to derangement of the stomach and 
intestinal canal good results are often obtained by 
a purgative dose of the sulphate daily before break- 
fast or by doses of 5 grains in water 3 or 4 times a 
day. The same salt, finely triturated, makes an ex- 
cellent dusting-powder for cases of acne rosacea. A 
saturated solution of magnesium sulphate, contin- 
uously applied, has beneficial influence on local 
inflammation, especially erysipelas and orchitis. 
In heartburn: 
3- Calcined magnesia, 3 ss 
Peppermint-water, 3 jss 
Tincture of orange, 3 j • 
Give at a draft. 
In dyspepsia with acidity: 
3- Magnesium carbonate, gr. xx 
Compound infusion of gen- 
tian, 3 xj 
Compound tincture of car- 
damom, 5 j. 
Give at a draft, twice daily. 
In obstinate constipation: 
3- Magnesium sulphate, 3 ij 
Glycerin, 3 j 
Water, 3 iv. 
Use as a rectal injection. 
Incompatible with magnesium oxid are: Acids, 
copaiba (forms a solid mass), water (in small 
quantity hydrates it). With magnesium salts 
are: Alkalies, arsenates, carbonates, lead acetate, 
lime-water, oxalates, phosphates, silver nitrate, 
sulphites, tartrates. 
Preparations.-M. Carbonas-light, friable 
masses, or powder, odorless and tasteless, insoluble 
in alcohol, almost insoluble in water. Dose, 10 to 
60 grains. M. Oxidum, magnesium oxid, magnesia 
-is made by heating the light carbonate in a 
crucible to expel nearly all the carbonic acid. A 
white, light and very fine powder, almost insoluble 
in water, insoluble in alcohol, and gelatinizes 
with 15 of water after standing 1/2 hour, having 
become hydrated. It is a constituent of pul vis 
rhei compostitus, and ferri hydroxidum cum 
magnesii oxido. Dose, 10 to 45 grains. M. Oxi- 
dum Ponderosum, heavy magnesium oxid, heavy 
magnesia-is a. white, dense and very fine powder, 
corresponding in other properties and reactions to 
magnesia, except that it does not gelatinize with 
water. It is made by calcining the heavier car- 
bonate, and is much slower in action than the 
light magnesia. Dose, 10 to 45 grains. M. 
Sulphas (Epsom salt)-colorless prisms or aci- 
cular needles, slowly efflorescent, odorless, of 
cooling, saline taste, and neutral reaction, very 
soluble in water, insoluble in alcohol. Is a con- 
stituent of infusum sennae compositum. Dose, 
1 to 8 drams in plenty of water. M. Sulphas 
Effervescens-is prepared from the sulphate 50, 
sodium bicarbonate 40.3, tartaric acid 21.1, citric 
acid 13.6. A coarsely granular, white, deliques- 
cent salt, of acid taste and reaction, soluble in 
water, insoluble in alcohol. Dose, 1 to 8 drams. 
Liquor M. Citratis-prepared from the carbonate 
15, citric acid 33, syrup of citric acid 60, potassium 
bicarbonate 2 1/2, water to 360. Dose, 6 to 20 
ounces, for catharsis. 
MAGNET.-Strictly speaking, a magnet is a 
body having the power to attract the unlike pole 
of another magnet, or to repel the like pole, and PLATE I. 
THE QUARTAN PARASITE 
THE TERTIAN PARASITE. 
THE ESTIVO AUTUMNAL PARASITE 
Quartan 1, 2, 3, 4, 5, and 6, show the development from the hyaline form to the 
mature intracellular (6) and large extracellular (10) forms; 11 shows vacuolization 
of an extracellular form; 7, 8, 9, show segmentation stages; 12, the flagellate form. 
Note.-In the tertian and estivo-autumnal organisms the same phases are shown. 
Note.- 
A. Relative depth of color in the erythrocyte host, deepest in the quartan, lightest 
in the tertian. 
B. Comparatively coarse, scant, and dark granules of the quartan as compared 
with the tertian. 
C. Tendency to shrinkage in the erythrocyte host of quartan vs. large pale host of 
tertian. 
D. Peripheral arrangement of pigment in development stage of tertian and quartan 
followed by central grouping initiating segmentation. 
E. Greater regularity in quartan as compared with tertian forms. 
F. Relative number of segments. 
G. Greater density and clearer outline of quartan forms. 
H. Star-like arrangement of pigment in early segmentation stage of quartan. 
I. Relatively small flagellate forms of quartan and estivo-autumnal. 
J. The peculiar ovals and crescents of the developed estivo-autumnal form, its 
scantily pigmented spherical form (35) and the ring bodies of the early stage. 
-(.Greene's Medical Diagnosis.) 
DESCRIPTION. PLATE II. 
THE QUAKIAN PARASITE 
THE TESTI AN PARASITE 
THE, aESTIVOAVTVMNAL PARASITE 
Malarial organism of types shown in plate but treated with Wright's stain. 
Quartan Parasite. 
1. Non-pigmen ted form. 
2, 3, 4. Young organisms showing chromatin bodies (red) and pigment granules. 
5, 6. Full-grown parasites, the former intracellular, the latter extracellular. 
7, 8. Presegmentation forms. 
9. Segmentation. 
11. Normal blood cell. 
12. Flagellate body. 
Tertian Parasite. The forms are self-explanatory in connection with the preced- 
ing description. 
Estivo-autumnal Form. Various ring forms are shown together with the charac- 
teristic crescents, Nos. 32, 33, 34. 
(In both this and the preceding plate the drawings are almost entirely based upon 
personal observation, though certain forms have been adapted from Thayer's valuable 
monograph.)-(Greene's Medical Diagnosis ) 
DESCRIPTION. MALACOSTEON 
MALARIAL FEVERS 
also to attract easily magnetizable bodies. Lode- 
stone, an oxid of iron, is a natural magnet. The 
electromagnet is a piece of soft iron temporarily 
magnetized by induction or by insertion into a 
helix. The electromagnet is used for locating and 
extracting foreign bodies, especially from the eye. 
See Eyeball (Injuries). 
MALACOSTEON.-See Bone (Diseases). 
MALARIAL FEVERS (Malaria). Synonyms.- 
Chills and fever; ague; fever and ague; swamp fever; 
intermittent fever; remittent fever; paludism; 
miasmatic fever. 
Definition.-A specific infectious disease de- 
pending upon the presence in the blood of a 
protozoan parasite, the hematozoon or plasmo- 
dium malarias of Laveran, which develops within, 
and at the expense of, the red blood-corpuscles of 
the infected individual, resulting, according to the 
species and number of the parasites present, in 
more or less periodic febrile paroxysms or in con- 
tinued fever. 
Distribution of the Disease; Climatic and Telluric 
Conditions under Which Malaria Prevails; Manner 
of Infection.-Malarial fever is especially prev- 
alent in moist tropical districts, but occurs in 
almost all parts of the world, being absent only 
from the coldest regions. The most pernicious 
forms are seen in tropical Africa, India, South 
America, the East and West Indies; here the dis- 
ease prevails throughout the year. In temperate 
countries malaria is most prevalent during the 
later summer and early fall. Moisture favors the 
development of the disease, which is particularly 
frequent in lowlands bordering upon rivers, lakes, 
and marshes; it is rare in mountainous districts. 
Drainage and cultivation prevent the disease, 
while extensive turning up of soil often gives rise 
to an outbreak. In malarious regions unaccount- 
able cycles of variation in severity and frequency 
of the disease often occur. Mosquitos prevail in 
all regions and under all conditions favorable to 
malaria. The dark-skinned races are much less 
susceptible to the disease than are the whites. 
The Manner of Infection.-The only mode of 
infection is through the bites of mosquitos belong- 
ing to the genus anopheles. The experiments and 
observations of Manson, Ross, Grassi, Bignami, 
and Bastianelli have shown that certain varieties 
of mosquitos are normal intermediate hosts of the 
hemameba malariae, which undergoes a sexual 
cycle of existence, lasting about 10 days, in the 
walls of that insect's intestine. At the end of the 
period large numbers of sporozoids become stored 
in the cells of the salivary gland, from which they 
are introduced into the human body with the bites. 
In its human host the parasite reproduces itself 
asexually by sporulation. It breaks up into 
sporocytes each of which penetrates a red blood 
cell in which it grows and upon which it feeds. 
When mature it breaks into spores. Some of the 
sporocytes, however, are sexual cells, gametocytes, 
and do not break up into spores. If they gain 
entrance into the mosquito they reproduce them- 
selves sexually. See Mosquitos. 
The period of incubation lasts apparently from 
several days to several weeks. 
The Infectious Agents.-The hemamebae ma- 
lariae were discovered in 1880 by Lave ran. They 
have since been shown to belong to the class of 
sporozoa, order of Hemosporidia. Three distinct 
species of the parasite have been differentiated: 
(1) The tertian parasite; (2) the quartan parasite; 
(3) the estivoautumnal parasite. 
The first two parasites are associated with more 
or less regularly intermittent fevers; the last 
variety with fevers which may be regularly inter- 
mittent, but are more often irregular or continued. 
1. The Quartan Parasite.-This organism exists 
in the blood in great groups, all the members of 
which are approximately at the same stage of 
development and pass through their cycle nearly 
in unison. The cycle lasts almost exactly 72 
hours, at the end of which time the parasites 
which have reached maturity undergo sporulation, 
the fresh spores attacking new corpuscles. Sporu- 
lation of a group of parasites, if it has reached a 
sufficient size, is always associated with a par- 
oxysm in the infected individual. The immedi- 
ate cause of the malarial paroxysm is thought to 
be the liberation of some toxic substance, probably 
by the parasites at the time of sporulation. 
Not infrequently 2 or 3 groups of parasites are 
present. When this is the case, they almost 
always reach maturity on different days, resulting 
in paroxysms on 2 successive days, with a day of 
intermission between, or in daily paroxysms. Very 
rarely the presence of multiple groups causes ir- 
regular or continued fever. In a triple quartan 
infection the disease assumes a daily or quotidian 
type.. 
In its youngest form the quartan parasite is rep- 
resented by a minute, colorless disc, about 1 mm. 
in diameter, lying within the red corpuscle. This 
shows more or less active ameboid movements. 
As it increases in size the activity of the ameboid 
movements diminishes, and fine, dark pigment 
granules begin to develop. These show a lazy 
motion in the younger forms, but are almost 
motionless in the adult bodies. The pigment 
granules lie about the periphery of the para- 
site, the outlines of which are usually quite dis- 
tinct. The red corpuscle tends to retract about 
the growing organism, and sometimes assumes a 
somewhat deeper, slightly brassy color. At the 
end of about 3 days the parasites reach a size about 
two-thirds that of the normal red corpuscle, while 
the rim of the retracted corpuscle becomes almost 
imperceptible. At this stage the pigment begins to 
collect toward a single point, usually at the center 
of the parasite, flowing in radial lines. The 
organism then breaks up into from 6 to 12 radially 
arranged leaflets, surrounding the central pigment 
like a roset. Finally, the surrounding shell of 
red blood-corpuscle ruptures and the separate 
segments spring apart, appearing as small, round, 
colorless bodies. These represent complete young 
parasites, and immediately attack new red blood- 
corpuscles, to pursue again their cycle of existence. 
Not all adult bodies undergo segmentation. 
Some become vacuolated and fragmented, a proc- 
ess indicative probably of degeneration. From 
other full-grown bodies there are developed, at MALARIAL FEVERS 
MALARIAL FEVERS 
times, actively motile filaments (flagella), which 
will be spoken of later. 
2. The Tertian Parasite.-The tertian parasite, 
like the quartan, exists in the blood in great groups. 
Its life cycle, however, lasts but 48 hours, so that 
sporulation occurs every other day. Infections 
with 2 groups of organisms segmenting on succes- 
sive days are common, the disease assuming a 
quotidian or daily type. Infections with multiple 
groups, causing irregular or continued fever, occur, 
but are rather uncommon. 
The tertian parasite shows certain morphologic 
differences from the quartan organism. In the 
early stages the parasites are more actively ame- 
boid ; the pigment granules are smaller, more 
motile, and show less tendency to accumulate 
about the periphery of the body. The parasite 
is paler and less refractile, and at maturity reaches 
a larger size. The surrounding corpuscle expands 
with the growth of the parasite and becomes 
progressively decolorized. At segmentation the 
pigment does not flow in toward the center in 
such characteristic radial lines as in the quar- 
tan organism, while the number of segments is ma- 
terially larger, ranging usually from 12 to 20 or 
even 30. 
3. The Estivoautumnal Parasite.-This variety 
is responsible for the more serious, more chronic, 
malignant or pernicious forms of malaria. The 
estivoautumnal parasite differs from the tertian 
in that the regular arrangement in groups is less 
frequent. When this is the case at the beginning 
of an attack, multiple groups, as a rule, rapidly 
appear, resulting often in the development of 
irregular or continued fever. The parasite of 
estivoautumnal fever is smaller than the tertian 
or quartan organisms, and, as a rule, only the 
earlier stages are to be found in the peripheral cir- 
culation. The later stages and segmenting forms 
are to be found only in internal organs, especially 
the bone-marrow, spleen, or, in some pernicious 
cases, in the brain or intestine. The earliest stages 
are represented by very minute, colorless bodies, 
which often are sharply refractive, and frequently 
assume a ring-like appearance. Commonly, these 
ring-like forms show rapid transitions into disc- 
like or actively ameboid bodies. The amount of 
pigment contained is relatively slight, the earliest 
granules being so minute as to be almost imper- 
ceptible. At full development the parasites may 
be no more than half the size of a red corpuscle. 
Segmentation occurs in the same manner as in the 
tertian parasite. 
A certain number of full-grown forms do not, 
however, segment, but accumulate larger, coarser, 
pigment granules, and develop gradually into an 
ovoid or crescentic shape, about which the rim of 
the red corpuscle may, with difficulty, be dis- 
tinguished. Usually only a bit of red corpuscle is 
visible, hanging from the concave side of the cres- 
cent. At times these bodies may be seen to 
change into round forms with a central clump or 
ring of pigment. 
The Flagellate Forms (Gametocytes).-In all 
three forms of parasites delicate motile filaments 
may develop from certain full-grown forms. In 
the estivoautumnal organism these come only 
from the round bodies derived from crescents. 
Their appearance is preceded by extremely active 
dancing movements of the pigment granules,, after 
which suddenly from 1 to 4 of such filaments, 2 or 
3 times the length of the diameter of a red cell, 
break out from the periphery. These are at first 
attached to the mother body, but often break loose 
and swim about with active serpentine motion. 
In several instances these bodies have been ob- 
served to penetrate other full-grown parasites. 
The significance of flagellate bodies has long been a 
question of dispute. The remarkable observations 
of McCallum, however, make it extremely probable 
that they are sexual elements, the penetration 
representing a process of fecundation. It is ap- 
parently only these fecundated bodies which are 
capable of undergoing further development within 
the stomach-wall of the mosquito. 
Symptoms.-The symptoms of malarial fever 
differ according to the species of parasite with 
which the individual is infected. 
Quartan Fever.-In infections with a single group 
of the quartan parasite the symptoms consist of 
regularly intermittent paroxysms occurring every 
fourth day at nearly the same hour. The parox- 
ysm consists of 3 stages: (1) Chill; (2) fever; 
(3) sweating. The entire duration of the fever, 
which begins often before or during the chill, 
amounts to as much as 10 to 12 hours in severe 
cases. The chill varies greatly in intensity, and 
may be entirely absent, though chilly sensations 
are present in over 95 percent of the cases. This 
is followed by a sensation of extreme heat, which 
may last from but a short time to several hours. 
Both stages are often associated with severe head- 
ache, pains in the back and extremities, nausea, 
vomiting, and sometimes diarrhea. The febrile 
stage is usually succeeded by profuse sweating, 
the temperature rapidly falling, generally to a 
subnormal point, the patient experiencing great 
relief from all his symptoms. Between paroxysms 
the temperature is usually subnormal. 
Infections with 2 or 3 groups of parasites fol- 
lowing on different days, resulting in paroxysms 
occurring on 2 successive days, with a day of 
intermission between, or in daily paroxysms are 
common. Occasionally irregular or continued 
fever, as a result of infection with multiple groups 
of parasites, may be present. 
Tertian Fever.-The paroxysms here occur 
every other day. Infections with 2 groups of 
tertian parasites are very common, resulting in 
daily paroxysms. Multiple infections with irregu- 
lar fever are rare. 
Tertian and quartan fever are the commonest 
types in temperate climates, and in the more 
severely malarious regions prevail during the 
healthy season. 
Estivoautumnal Fever.-Estivoautumnal fever 
is the prevailing type in the severely malarial 
districts of the tropics, and occurs in temperate 
regions only at the height of the malarial season. 
The manifestations differ from those of tertian and 
quartan fever, (1) in that the paroxysms are, as 
a rule, much more irregular; (2) they are much MALARIAL FEVERS 
longer in duration; (3) the chills are more fre- 
quently absent; (4) the fever is often irregularly 
intermittent, remittent, or continuous in character, 
owing probably to the presence of multiple groups 
of parasites. 
When the fever is regularly intermittent, the 
paroxysms occur usually about 48 hours apart; the 
intervals, however, may be as short as 24 hours, 
and in other instances longer even than 48. As a 
general rule, the longer the interval, the longer is 
the paroxysm, which may, in some instances, 
last more than 36 hours. When the fever is 
irregular and continuous and chills are absent, the 
clinical picture may closely resemble that of 
typhoid fever. 
The spleen is enlarged in all forms of malaria, 
and in the majority of instances it is palpable. 
Herpes on the lips is common. Urticarial erup- 
tions are occasionally seen. 
Pernicious Fevers.-With severe estivoautum- 
nal infections the malarial paroxysms may assume 
an extremely malignant, and often rapidly fatal, 
form. These intense infections are often referred 
to as "pernicious." There are several well- 
recognized types of pernicious fever. 
The comatose type is the commonest. With the 
onset of the paroxysm the patient becomes pro- 
foundly unconscious. Local paralyses or irri- 
tative symptoms may be present. 
In other instances the pernicious paroxysm may 
assume an algid, choleriform, hemorrhagic, sudor- 
ific, bilious, gastralgic, or pneumonic type. The 
picture in choleriform malaria may be similar to 
that in Asiatic cholera. 
Malarial Hemoglobinuria.-The malarial par- 
oxysm may be accompanied by hemoglobinuria. 
These instances are unusual, excepting in certain 
very malarious tropical districts. This extremely 
grave condition of paroxysmal hemoglobinuria is 
also known as black-water fever. The symp- 
tom usually arises in individuals who have had 
repeated attacks of malaria; rarely or never does 
it occur with the first manifestations of the disease. 
Sometimes, if the first attack is not fatal, several 
successive paroxysms may be accompanied by 
hemoglobinuria. More commonly, however, the 
recovery from a hemoglobinuric paroxysm is 
followed by at least a temporary disappearance of 
the symptoms of malaria. This is probably due to 
the fact that with the extensive blood destruction 
the parasitiferous corpuscles are almost all de- 
stroyed, and the parasites, being set free, are killed. 
Often the hemoglobinuric attack is postmalarial. 
In all instances the onset occurs with an intense 
chill, rapidly followed by the passage of deep red 
and then almost black urine. If death does not 
occur during the immediate paroxysm, it may 
follow shortly afterward from complete suppression 
of the urine, or, after several weeks, from a severe 
acute nephritis. See Black-water Fever. 
Malarial Paroxysms with Long Intervals.-Cases 
of malaria may occur in which the paroxysms 
occur at long intervals-5 or 6 days to several 
weeks. These symptoms, which may occur with 
all 3 types of infection, are due to the fact that so 
many parasites are destroyed at the time of sporu- 
lation that practically a new incubation period 
must be passed through before the number is 
sufficient to cause symptoms again. 
Sequels and Complications.-Relapses are fre- 
quent in ill-treated malaria. They may occur 
after long periods-months, and even years. 
There is no essential difference between the symp- 
toms of the relapse and the initial attack. 
Anemia.-Owing to the destruction of red blood- 
corpuscles, resulting from the growth of the para- 
site, anemia is a common sequel. In some in- 
stances it may assume a pernicious type. 
Chronic Malarial Cachexia.-In patients with ill- 
treated or frequently recurring infections, a con- 
dition of grave cachexia sometimes develops. 
There are marked anemia, enlargement of the 
spleen and of the liver, and a tendency toward 
dropsical effusions. 
Nephritis.-Acute nephritis may accompany or 
follow an attack of malarial fever, as of any other 
severe acute infection. The course is usually mild, 
though sometimes grave chronic changes may 
follow. 
Amyloid degeneration has been noted after long- 
continued and frequently recurring malaria. 
There is some evidence that cirrhosis of the 
liver may follow malaria. Its frequency, however, 
is probably much exaggerated. 
Peripheral neuritis may occasionally occur. 
Complications.-Mixed Infections.-Pneumonia, 
typhoid fever, tuberculosis, or any acute infectious 
disease may complicate malaria. An individual 
with malarial cachexia is probably more susceptible 
to most acute infections than a healthy subject. 
There is nothing especially characteristic about the 
course of these cases. 
Pneumonia, as a complication of malaria, pur- 
sues its usual course. 
In individuals with combined typhoid and ma- 
larial infections the malaria usually remains quies- 
cent during the course of the typhiod fever, re- 
appearing again with or after defervescence. 
Sometimes, however, active symptoms of the two 
diseases may be present at the same time. These 
instances are, however, unusual. There is nothing 
to show that the course of typhoid fever in malari- 
ous districts differs in any essential way from that 
in other parts of the world. 
Pathologic Anatomy.-In individuals dead from 
acute malaria there is more or less marked pig- 
mentation of all the organs. The spleen is always 
greatly enlarged and soft. The other changes 
depend upon the especial localization of the para- 
sites, which varies in different cases. When the 
brain is especially affected, the capillaries are 
crowded with parasites, actual thromboses some- 
times occurring. There may be numerous punctate 
hemorrhages. Finer degenerative changes in the 
neurons themselves have been described by Monti. 
In other instances the organisms seek especially the 
mucous membrane of the stomach and intestines, 
resulting in great injection of the mucosa with 
hemorrhage and superficial ulceration. The liver 
is enlarged, shows great numbers of parasites and 
macrophages in its capillaries, and often areas of 
focal necrosis not dissimilar to those seen in other 
MALARIAL FEVERS MALARIAL FEVERS 
MALARIAL FEVERS 
acute intoxications. Similar areas are to be 
found in the spleen and the bone-marrow, where 
great accumulations of parasites and pigment are 
also to be found. 
In chronic cases the spleen is enormously en- 
larged and shows extensive fibrous changes. 
Similar changes are sometimes to be found in the 
liver and bone-marrow. 
Diagnosis.-In most instances the diagnosis of 
malaria is simple, and based upon the nature of 
the paroxysms-chill, fever, sweating-and their 
characteristic periodicity. 
Chills and fever, however, do not of necessity 
mean malaria and a positive diagnosis is only to 
be made by an examination of the blood and the 
discovery of the parasites. Examination of the 
blood is, perhaps, best made with the fresh 
specimen though the examination of dried and 
stained blood films, prepared according to the 
ordinary methods, is also satisfactory. 
The disappearance of the symptoms under 
treatment with quinin is strong confirmatory evi- 
dence that the process is malarial. 
In instances of continued or remittent fever the 
process may so far simulate typhoid that the dis- 
tinction is impossible without an examination of 
the blood or the therapeutic test. 
Prognosis.-In temperate climates the prognosis 
is almost always good. This is always true with 
tertian and quartan fever. In estivoautumnal 
fever there is always a certain danger that per- 
nicious symptoms may appear. 
Pernicious Malaria.-The prognosis, when perni- 
cious manifestations appear, is always very grave. 
In the comatose cases death may occur a week or 
more after the beginning of treatment, when the 
blood is entirely free from parasites, a result, 
apparently, of the grave anatomic and chemic 
changes produced by the acute infection. 
Hemoglobinuria.-The prognosis in hemoglob- 
inuria, occurring with or after malaria, is always 
grave. 
Prophylaxis.-Since extermination of the mos- 
quitos belonging to the genus anopheles means the 
wiping out of the disease, attempts should be 
made to destroy the larvae by disinfection (with 
kerosene) and drainage of the breeding places, and 
by removal of stagnant water. See Disinfection. 
Mosquitos should be excluded from houses by 
wire netting. Careful screening of the malarial 
patient is important, in order to prevent infection 
of mosquitos. Exposure after nightfall should be 
avoided since the mosquito is chiefly nocturnal in 
its biting habits. Quinin has been proved to be 
of decided value as a prophylactic and 5 to 10 
grains should be taken daily by new arrivals in 
malarial districts and also at intervals by the 
residents. Arsenic and iron are advocated by 
some observers as prophylactics; their value, 
however, probably lies in their increasing the 
quality and quantity of red blood-corpuscles. 
Treatment.-In every case of acute malaria the 
patient should, if possible, be compelled to give up 
his occupation for at least 2 days. He should have 
physical and mental rest. If there is constipation, 
a purgative should be given. Medicinally, the 
treatment is simple and absolutely satisfactory, 
consisting in the administration of quinin. This 
is best given in solution. A favorite prescription 
is as follows: 
I|. Quinin sulphate, 3 j 
Dilute hydrochloric acid, 3 j 
Simple elixir, 3 iij 
Water, enough to make 3 iij. 
Two teaspoonfuls every 4 hours. 
With an adult it is well, perhaps, to give 5 grains 
of quinin 3 or 4 times a day for the first several 
days, and, later, 2 grains 3 or 4 times a day. 
In patients who are readily cinchonized and are 
unable to take large doses, complete cure may be 
obtained by doses as small as 2 grains 3 times a 
day, if the patient is kept at rest in bed. If the 
patient is seen during, or immediately after, a 
paroxysm, a single large dose-10 grains-will 
often prevent the next paroxysm which would 
come from that group of parasites. 
In estivoautumnal fevers it is always important 
to keep the patient in bed for several days if 
possible. In ordinary cases in temperate climates 
quinin, 5 grains every 4 hours, and continued for a 
week, and followed by a reduction in the dose to 
2 or 3 grains for several weeks afterward is usually 
quite sufficient. In all these instances treatment 
should be continued for at least 3 weeks. 
If the symptoms are severe, and it is desirable 
to obtain a more immediate effect, larger doses may 
be given immediately before or during the par- 
oxysm, at which time the action of the drug upon 
the parasites is most effectual. 
In pernicious paroxysms larger doses of quinin 
must be administered hypodermically or intra- 
venously. For this the dihydrochlorid or the 
hydrochlorid of quinin and urea is probably the best 
form in which to administer the drug. If given 
hypodermically, the injection must be made deeply 
in order to avoid abscesses which are otherwise 
frequent. Intravenous injections, which are es- 
pecially effectual and are to be recommended in 
pernicious cases, may be given into the median 
basilic vein. 
The following formulas may be suggested for 
hypodermic or intravenous use: 
1^. Quinin and urea hydro- 
chlorid, gr. x to xv 
Distilled water, 3 j- 
Or, 
1$. Dihydrochlorid of quinin, gr. xv 
Sodium chlorid, gr. j 
Distilled water, 3 ijss. 
This may be injected, 5 c.c. (75 minims) at a 
time, into the median basilic vein. 
The dihydrochlorid of quinin is soluble in less 
than its own quantity of water, and may be given 
hypodermically in a more concentrated form than 
in the case of other quinin salts. 
It is rarely necessary or wise to give more than MAL DE MER 
MALT 
15 grains at a dose. In pernicious paroxysms this 
may be repeated several times at intervals of 3 or 
4 hours, after which time it is generally advisable 
to reduce the quantity. It should be remembered 
that in pernicious cases moderate fever may exist 
for some days after the parasites have disappeared 
from the blood. In such instances large doses of 
quinin should be discontinued. 
Treatment of Hemoglobinuria.-The treatment 
of hemoglobinuria depends upon its relation to the 
malarial paroxysm. If acute malaria exists, as 
revealed by the presence of actual parasites, 
quinin should be administered intravenously or 
hypodermically. On the disappearance of the 
parasites it is advisable to reduce the quantity of 
quinin, continuing treatment as in any other case. 
If the parasite is absent, the case should be treated 
symptomatically-with rest and careful diet and 
tonics. Recrudescence of malarial paroxysms 
after an attack of hemoglobinuria should be 
treated in the ordinary manner. See Black- 
water Fever. 
The treatment of the various sequels of malarial 
fever presents no special points. 
Arsenic has a well-established reputation in the 
treatment of the grave postmalarial anemias and 
cachexias. 
3. Arsenic, gr. f 
Quinin, gr. xl 
Reduced iron, 3ij 
Extract of gentian, q. s. 
Make 30 pills or capsules. One pill or capsule 
after each meal. • 
The new arsenical compounds, especially sodium 
cacodylate, are recommended. 
In some of these instances the removal of the 
patient to a healthy region where there may be no 
danger of a reinfection may be imperative. 
MAL DE MER.-See Sea-sickness. 
MALE FERN.-See Aspidium. 
MALIGNANT EDEMA.-See Gangrene. 
MALIGNANT PUSTULE.-See Anthrax. 
MALINGERING.-The feigning of disease. The 
simulation of various morbid conditions is common. 
There are many cases of professional malingering, 
principally encountered by street car, railroad and 
accident insurance companies. The surgeon of 
the army, or navy, or prison must especially be on 
his guard against malingering. In the voluntary 
and short service attempts are not so usual. 
Headaches, rheumatism, colic, diarrhea, and 
other more or less subjective affections are com- 
plained of. In continental armies, mutilation and 
resort to imitation of chronic diseases are com- 
paratively common. To avoid conscription, an 
infinite variety of artifices is resorted to. Func- 
tional affections so closely simulate organic dis- 
ease that suspicion is often disarmed. Hysteria 
or neurasthenia explains the greater number of 
cases, a deranged nervous system being respon- 
sible. In these cases the simulation may be 
voluntary. In other cases the patient may vol- 
untarily exaggerate symptoms or add new ones to 
those already present. In a third group of cases 
fraud is attempted, through some strong motive, 
by deliberate simulation of an injury or disease. 
Paraplegia, incontinence of urine, joint affec- 
tions, in short, almost any disease which does 
not admit of palpable objective demonstra- 
tion, may be feigned. A sudden shock, the pres- 
sure of poverty, or the absolute necessity for im- 
mediate exertion will often effectually and per- 
manently arouse a bedridden hypochondriac of 
years, and restore him to usefulness and his friends. 
When face to face with the deliberate malingerer, 
natural cunning must be overcome by the superior 
sharpness of science. Incontinence of urine, dys- 
entery, hemoptysis, jaundice, and insanity are 
among the most favorite roles of such persons. 
The yellow conjunctivae of jaundice can hardly be 
feigned; incontinence of urine is often found at- 
tended by an expulsive effort; blood from the lungs 
is not always mixed with pulmonary mucus, and 
blindness, deafness, or paralysis are not always 
proof against some shock or mental impression. 
A blood test will determine whether an anemia is 
genuine or not. The X-ray will expose a feigned 
fracture. Skin lesions deliberately produced can 
be detected by the application of a fixed plaster- 
of-Paris dressing. Simulated cancer is readily 
disproved by microscopic examination. The 
stethoscope and absence of bacilli and fever will 
expose feigned tuberculosis. Epilepsy that is 
simulated may be detected by a hypodermic of 
apomorphin or a pinch of snuff. Feigned blind- 
ness and deafness may be discovered by special 
tests. See Blindness, Ear (Examination). 
Electricity may clear up apparently anomalous 
nervous symptoms; the stethoscope and sphygmo- 
graph record the actual condition of the heart. 
Administration of chloroform or ether will expose 
feigned contractures, wry neck, paralysis, as well 
as unconsciousness. Simulated unconsciousness, 
or anesthesia, may be detected by the electric 
current. Subjective sensations are hard to detect, 
and it is often well to give a patient the benefit of 
the doubt. 
MALLEIN.-An extract, in glycerin, of the 
products of cultures of the bacillus mallei, the 
microorganism of glanders. When injected into 
animals suffering from glanders, it causes a marked 
febrile reaction, as does tuberculin when injected 
into animals suffering from tuberculosis. See 
Glanders. 
MALPRACTICE.-A term applied to the treat- 
ment of a disease that is contrary to that taught by 
experience, or a failure on the part of a medical 
practitioner to use such skill, care, and judgment 
in the treatment of a patient as the law requires; 
and thereby the patient suffers damage. If due to 
negligence only, it is civil malpractice. But if 
done deliberately, or wrongfully, or if gross care- 
lessness or neglect have been shown, or if some 
illegal operation (such as criminal abortion) be 
performed, it is criminal malpractice. See Abor- 
tion. 
MALT.-The seed of common barley, germinated 
until the maximum amount of diastase, the 
ferment that converts starch into grape-sugar, is 
developed. It is nutritive and valuable also, for MALTA FEVER 
MANGANESE 
the diastase, which aids in the digestion of fari- 
naceous foods. It is employed in wasting diseases, 
preferably mixed with milk. Many popular 
"foods" consist mainly of granulated extract of 
malt. M. Ext., the soluble principles of malt, 
mainly diastase and glucose, in a concentrated 
form, unfermented. Dose, 1 to 8 drams. M. 
Liquors, fermented and clarified solutions of malt 
that have been subjected to vinous fermentation, 
hops being added to prevent acetous fermentation 
subsequently. Beer is made by a comparatively 
slow fermentation, and contains about 2.5 percent 
of alcohol. Ale and porter are fermented more 
rapidly, and contain about 4.7 per cent of alcohol. 
The malt used in making porter is browned, 
giving the liquor a darker color. Malt liquors 
contain about 5 percent of albuminous matter, 
2 of phosphates, and 1 of carbon dioxid. 
MALTA FEVER. Synonyms.-Mediterranean 
Fever, Neapolitan Fever, Rock Fever, Undulant 
Fever. An endemic fever observed along tropic 
or subtropic sea coasts or river banks, of 
irregular course, with undulatory pyrexial re- 
lapses, profuse sweats, rheumatic pains, arthritis, 
and enlarged spleen. It occurs chiefly in the 
countries bordering on the Mediterranean Sea. A 
number of cases have been observed, however, in 
Porto Rico, Cuba, the Philippine Islands, etc. 
The disease attacks most frequently the young. 
Etiology.-The cause of this infectious disease, 
the micrococcus melitensis, discovered by Bruce, 
is found in the spleen. It generally occurs singly, 
occasionally in pairs, or in chains, is aerobic and 
nonmotile, although according to some observers 
it has one or several flagella, and grows fairly well 
upon the ordinary media such as agar. Pale 
colonies are observed in about three days. 
In most cases infection can be traced to goat's 
milk, but not always. Even mere contact with 
the infected goats or with their blood may trans- 
mit the disease. Laboratory infection seems to 
occur more readily with Malta fever than with 
glanders or plague. A case is reported in which 
the probable source of the contagion was the 
patient's habit of laying his cigarette from time to 
time on his work table. 
Symptoms.-After an incubation period of about 
a week the disease develops gradually, the onset 
being marked by headache, anorexia, insomnia, 
and lassitude. The disease is of long and indef- 
inite duration. The undulations of pyrexial 
intensity are the most constant and characteristic 
feature of the disease. Constipation, profuse per- 
spiration, and frequent symptoms of neuralgic and 
of arthritic nature accompany its course. There 
is enlargement of the mesenteric glands. The 
spleen, too, is enlarged and softened after death, 
and many of the other organs are congested, but 
Peyer's patches are not enlarged or ulcerated, 
and ulceration is not present in other parts of the 
small intestine. There are no red spots. 
Diagnosis.-The disease may be overlooked 
because of its infrequency. It may be differen- 
tiated from typhoid fever by the negative Widal 
test, by the study of the temperature chart, from 
malarial fever by the absence of the plasmodium 
of malaria in the blood and by the therapeutic 
test. A most valuable means of diagnosis is the 
agglutination test-the serum of the patient's 
blood reacts upon fresh cultures of the micrococcus 
melitensis. The blood is allowed to stand for 24 
hours, the serum pipeted off, and it is diluted to a 
given degree, say 1:11, with distilled water, or 
even 1: 22, with normal saline solution, and added 
to some of the pure culture of the micrococcus. 
In distilled water the micrococcus retains its 
motility and does not clump for an indefinite 
time. With serum from a typhoid patient no 
reaction occurs. A control test should be made 
with normal blood serum from a healthy person. 
Treatment.-The general measures indicated for 
typhoid fever are advised. An initial dose of 
calomel or castor oil should be given. Food 
should be liquid during the febrile period, and 
either the cold bath or pack used every time the 
temperature reaches 103° F. Symptomatic treat- 
ment is otherwise indicated. No drugs have any 
special influence on the fever. Serum therapy 
does not seem very promising. One case, how- 
ever, is reported to have been cured by the ad- 
ministration of Malta fever antitoxin. During 
convalescence iron and plenty of nourishing food 
are indicated. A change of climate may promote 
convalescence. 
MAMMARY ABSCESS.-See Breast (Diseases). 
MANGANESE.-Mn = 54, quantivalence II, IV. 
A silver-white metal having the general properties 
of iron. It is used in medicine and pharmacy in 
the form of oxid, sulphate, permanganate, and 
hypophosphite. 
Therapeutics.--The salts of manganese in small 
doses improve the appetite and the digestion and 
stimulate the action of the heart. Potassium per- 
manganate is a powerful oxidizing agent, and 
hence is actively antiseptic, disinfectant, and 
deodorant; but its germicidal power is limited. It 
is considered by some authorities to be an efficient 
emmenagog. Used internally, it is probably not 
absorbed in its own state. 
The salts of manganese are used in amenorrhea, 
gastrodynia, and pyrosis, and in many skin-diseases 
and in jaundice. Manganese is becoming more of 
an acknowledged remedy in derangements of the 
menstrual function, as irregular or scanty men- 
struation, amenorrhea, menorrhagia, and even 
metrorrhagia. The best preparation is the dioxid, 
in freshly made pills of 2 grains each, of which 1 to 
5 pills may be taken twice or thrice daily. 
Potassium permanganate has generally been the 
preparation given when the effects of manganese 
were desired; but it is a difficult matter to get pa- 
tients to take it for any length of time. It is em- 
ployed as an antiseptic and oxidizing agent in such 
affections as diphtheria, scarlatina, septicemia, 
erysipelas, etc., in which it may be given internally 
and used locally at the same time. It is given 
with apparent benefit in dyspepsia, flatulence, 
lithemia, and obesity, and has often seemed to be 
of service in acute rheumatism. In amenorrhea 
it is reported to be very efficient, and has lately 
been used with success as a remedy for the bites 
of venomous serpents and for other animal MANIA 
MANIA 
poisons. For internal use the drug should be 
given in pill, as the taste of a solution is very dis- 
agreeable. Locally, it is frequently employed 
(1 dram to the pint) to correct fetor in cancer, ulcer, 
caries, abscesses, ozena, and it will destroy the 
odor of a foul breath or that of the fetid perspira- 
tion of the feet. It is used both as a test and as a 
corrigent for organic impurities in drinking-water. 
The stain left on fabrics may be removed by sul- 
phurous acid, but, as sulphuric acid is formed in 
the reaction, the fabric should be immediately 
washed or rinsed in water. Potassium perman- 
ganate has lately come into use as an antidote 
against morphin or opium in the stomach. It 
exerts no oxidizing effect, in the presence of al- 
bumin, on atropin, hyoscyamin, hyoscin, caffein, 
cocain, aconitin, veratrin, pilocarpin, muscarin, 
or phosphorus (Murrell). 
Preparations.-M. Dioxidum Praecipitatum, is 
chiefly manganese dioxid, MnO2, with small 
amounts of other oxids of manganese; a heavy, 
fine black powder, odorless and tasteless, insoluble 
in water or alcohol, giving off oxygen gas at a red 
heat, and if heated with hydrochloric acid it 
causes the evolution of chlorin gas. Dose, 2 to 
10 grains. M. Sulphas, colorless prisms, of 
slightly bitter and astringent taste and faintly 
acid reaction, very soluble in water, insoluble in 
alcohol. Dose, 2 to 6 grains. Potassii Perman- 
ganas, deep, purple-violet prisms, of sweet and 
astringent taste, neutral reaction, soluble in 16 
parts of water with a scanty, brown residue, decom- 
posed by alcohol and heating to 464° F. It 
should be kept in well stoppered bottles, and should 
not be triturated or combined in solution with 
organic or readily oxidizable substances. Dose, 
1/2 to 2 grains in pill. For the Hypophosphite, 
see Phosphorus. 
MANIA.-A form of insanity marked by great 
exaggeration of nervous action. It may occur sud- 
denly or follow an attack of melancholia. The 
patient presents an infinite variety of moods, is the 
subject of hallucinations and illusions, often shows 
a tendency to destroy what he comes in contact 
with, and is untidy; there is a marked change in 
character and decided insomnia. There is rapid 
and progressive emaciation. The brain is found 
to be in a hyperemic condition. The disease is 
probably due to a loss of the inhibitory action of 
the highest controlling centers of the brain. 
Mania is most common in young adult life. Hered- 
ity is a strong predisposing cause, while mental 
strain, bereavements, shocks, and alcoholism may 
act as exciting causes. 
Varieties.-Acute delirious mania, typhomania, 
is a psychosis of sudden onset, attended with in- 
creased bodily temperature, and marked by de- 
lirium with sensuous hallucinations, marked in- 
coherence, restlessness, refusal of food, loss of 
memory, and rapid bodily wasting, terminating 
frequently in death. 
The term menstrual mania is often used for 
attacks of mania occurring at the menstrual epoch. 
Homicidal, suicidal, and various hysteric impulses 
are common. 
Mania-a-potu is an attack of acute delirium 
during a debauch, or in those who have drunk 
heavily and eaten little for a comparatively short 
time. See Alcoholism. 
Asthenic mania is mania in which there is a 
general anemia associated with neurasthenic 
symptoms. See Hysteria, Neurasthenia. 
Dancing mania is a hysteric mental state in 
which, through sympathy and imitation, dancing 
of a most grotesque and extravagant character 
occurs. Usually epidemic. 
Delusion mania is the result of fixed delusions, 
either causing or associated with the maniacal 
outbreak. See Delusion. 
Erotic mania, erotomania, presents systematized 
delusions of an erotic character, not necessarily 
accompanied by animal sexual desire. 
Nymphomania is a morbid, irresistible impulse to 
satisfy the sexual appetite, peculiar to the female 
sex. I 
Epileptic mania follows an epileptic paroxysm, 
and is often of a most violent kind, the maniacal 
acts being of the most treacherous and malicious 
character. See Epilepsy. 
Hallucination mania presents visual, olfactory, 
and other sense hallucinations. See Hallucina- 
tion. 
Homicidal mania is any variety of mental dis- 
ease in which there is a desire or an attempt on the 
part of the patient to commit murder. The con- 
dition may be the result of delusions that the per- 
sons attacked either are persecuting or going to 
kill the patient, or of the excessive excitement that 
vents itself in destructiveness, combativeness, or 
desire to kill; or there may be a morbid desire, 
impulse, or craving to do murder, or the homicidal 
act may be unconsciously done during an acute 
delirium or a paretic or epileptic maniacal impulse. 
Morphinomania is the insane craving for the 
stimulating action of morphin-a moral insanity. 
See Opium. 
Puerperal mania is the maniacal outbreak occa- 
sionally seen in puerperal women. This is now 
thought to be of septic origin, although the mental 
strain through which the female has been passing 
is a predisposing factor. 
Recurrent mania, or chronic mania, with lucid 
intervals of longer or shorter duration. Generally 
of alcoholic origin. 
Transitory mania, or ephemeral mania, is a rare 
form of maniacal excitement, of sudden onset, 
violent and decided in character, accompanied by 
great insomnia, incoherence, and more or less 
complete unconsciousness of familiar surroundings. 
The attack as suddenly terminates, the duration 
being from a few hours to a few days. 
Senile mania is the mental exaltation occurring 
in persons with senile arterial changes or senile 
cerebral atrophy. It is soon followed by dementia. 
Prognosis.-In about 50 percent of the cases of 
acute mania not due to organic disease, the pa- 
tients recover after periods varying from 1 month 
to several years. A fair proportion make a 
partial recovery and are able to return to their 
work, but always showing some alteration in 
character or affection or some eccentricity or a 
slight mental weakness. About 20 percent termin- MANNA 
MARASMUS 
ate in dementia or mental death, and this is 
always the fear in each case. Two percent die, 
either the result of exhaustion or from the organic 
condition causing or associated with the attack. 
The question of recovery, partial or complete, is 
always difficult to determine, depending upon the 
cause, temperament, disposition, education, nation- 
ality, and the normal mentality of the individual. 
Recovery is usually gradual; rarely sudden re- 
storation occurs. 
Treatment--Persistent administration of drugs 
appears to have a deteriorating influence on the 
nerve-centers and their routine use is condemned. 
It is not advisable to restrain disorderly actions by 
mechanic means. The best measure to adopt in 
acute mania is to get the patient to be in the fresh 
air and work off as much excitement as possible by 
muscular exercise. Walking a patient about all 
day will often prove the best hypnotic, and sleep 
obtained in this way is more valuable than that 
procured through drugs. In acute cases forced feed- 
ing is sometimes necessary, and it is important that 
abundant nutriment be introduced into the system. 
Stimulants are often useful, and should be given 
with food. A dry tongue is an indication for 
pushing the administration of food and stimulants. 
Acute mania is with difficulty treated at home, 
and it is often advisable to remove the patient 
from his home surroundings. Moral treatment is 
far more efficacious than drugs in acute mania. 
In acute delirious mania the great effort should be 
to produce sleep by various methods. Opium 
must not be given, as it may produce a slight 
narcotism for a short time only, and, if the dose is 
increased, narcotic poisoning and death ensue. 
Hyoscin finds its greatest and most useful applica- 
tion in maniacal violence and noisiness. Coniin, 
1/2 to 3 minims, or 1/10 of a grain hypodermically, 
conjointly with morphin, is used in acute mania. 
Duboisin, 1/100 of a grain hypodermically; or 1/100 
of a grain by the mouth, gradually increased to 
1/30 of a grain of hyoscyamus, when there is no 
congestion; chloral and bromids, large doses of 
gelsemium, as 15 to 30 minims, stramonium, 
belladonna, daturin, veratrum viride, and cam- 
phor, cannabis indica, paraldehyd, and digitalis 
are variously useful. Tincture of iron chlorid, 
in 5- to 10-minim doses, is of benefit as a restora- 
tive in chronic mania. Croton oil, 1/4 to 1/3 of a 
minim, every hour, is used as a revulsive in mania 
from acute congestion of the brain. Cimicifuga is 
often efficient in puerperal mania or that of a 
pregnant condition. It may be necessary, to 
temporarily control violent cases, to employ 
chloroform by inhalation. The cold douche 
applied to the head while the patient's body is in a 
warm bath is of service in maniacal delirium. In 
congestive cases, ice may be applied to the head. 
Galvanism is also applied to the head and cer- 
vical sympathetic region in chronic mania. See 
Delirium. 
MANNA.-The concrete, saccharine exudation 
of Fraxinus Ornus, the flowering ash, and other 
trees. It contains from 40 to 90 percent of 
mannit, or manna-sugar, which does not undergo 
vinous fermentation, and is chemically allied to 
the alcohols and to glycerin. It also contains 
glucose, mucilage, some acrid resin, and a small 
quantity of the glucosid, fraxin. There are no 
official preparations, but manna itself may be 
given in doses of 1 to 8 drams. Manna is a mild 
laxative, with some tendency to produce flatulence 
and colic. It is usually combined with other 
purgatives, as senna, rhubarb, and magnesia, to 
disguise the taste and increase the effect. It is a 
constituent of the official infusum sennae com-: 
positum. Manna may be administered dissolved 
in milk. 
MARASMUS (Infantile Atrophy; Simple Wast- 
ing).-The form of wasting termed marasmus is a 
nutritional disorder, and occurs independently of 
any constitutional disease, as tuberculosis or 
syphilis, in which diseases, of course, an extreme 
condition of wasting is seen. 
Etiology.-Marasmus occurs in bottle-fed babies. 
It is rare in country children, and in those in the 
city who have good care and hygienic surroundings, 
but is common in dispensary practice, among the 
poor and neglected. The principal causes, there- 
fore, are improper feeding, and lack of sunlight, 
fresh air, and healthful surroundings. Excepting 
the atrophied condition of the muscular system, 
there are no characteristic pathologic lesions. All 
the organs after death may be found in an appar- 
ently normal condition. 
Symptoms.-The symptoms are those of starva- 
tion-the child steadily loses weight and strength. 
The eyes are large and sunken, the fontanels usu- 
ally open, the skin becomes wrinkled and hangs 
from the bones in folds, and the child presents an 
old appearance. The appetite, which early may 
have been good, diminishes, and after a time be- 
comes nearly lost. In other cases it is irregular, 
being ravenous at times. The bowels may be 
normal, but are more often constipated or irregu- 
lar, and contain a large proportion of curds. 
Vomiting at times is a prominent symptom. The 
child is usually listless or apathetic. The tem- 
perature is generally subnormal (96° to 97° F. per 
rectum). Unless arrested by treatment, the course 
is steadily downward, death occurring from the 
extreme degree of malnutrition or exhaustion, 
or from an intercurrent disease. 
The prognosis in a child under 6 months old is 
very unfavorable, and even while they are im- 
proved by treatment, relapses are likely to occur. 
Older children more frequently recover. 
Treatment.-Hygienic treatment is important, 
and consists in daily bathing, massage with 
oil, warm clothing, and, if the temperature 
is subnormal, external heat by hot-water bot- 
tles, etc. 
In order to expand its lungs the child should be 
made to cry once or twice a day by mild flagella- 
tion or alternate hot and cold baths. 
The principal treatment is the institution of 
proper feeding. When practicable, wet-nursing 
will be the best means of giving nourishment, but 
in cases in which this method cannot be used, a 
properly modified milk diet must be given. No 
set rules can be laid down for all cases, as the di- 
gestive powers will be found to vary, but generally MAR JOLIN'S ULCER 
MASSAGE 
a mixture, such as that given below, will be found 
to agree with a weak child 4 or 5 months old: 
Massage means treating the soft parts, muscles, 
organs, etc., only, while by Swedish movements is 
meant the movements of the joints, as flexion, 
extension, adduction, abduction, pronation, supin- 
ation, traction, etc. 
Metzger, of Wiesbaden, divides massage into 4 
principal manipulations: 
1. Effleurage (Stroking).-(1) With palm of one 
hand, used on small surfaces. (2) With palms 
of both hands, used on large surfaces (is most 
generally used). (3) With thumb or thumbs, on 
tendons or between muscles or small surfaces. (4) 
With tips of fingers, on tendons or between muscles 
or small surfaces. Light stroking has a soothing 
influence on the system; heavy stroking has a stim- 
ulating influence on the' superficial structures, 
increasing the arterial, venous, and lymphatic 
circulation. 
2. Frictions (Firm Circular, Semicircular, or To- 
and-fro Motions).-(1) With one hand, used on 
small surfaces. (2) With both hands, used on 
large surfaces. (3) With thumb or thumbs, used 
on small surfaces, as the face, below the eyes, 
hand, around joints. (4) With tips of fingers, 
used on small surfaces, as the face below the eyes, 
hand, around joints. This manipulation reaches 
deeper than the former, to the subcutaneous con- 
nective tissue and fat overlying the muscles, its 
aim being to transform pathologically changed 
parts into a condition that will permit them to be 
incorporated into the healthy tissues by absorption 
by the veins and lymphatics. 
3. Petrissage (Kneading or Pinching).-(1) 
With two thumbs, used to get the effect upon a 
certain small localized area. (2) With thumb and 
fingers. (3) With two hands, used on large sur- 
faces. (By pinching is meant the squeezing of the 
muscles between the fingers and the fleshy part of 
the palm.) The aim of this manipulation is to 
reach the separate muscles or groups of muscles; 
to reach as deep as possible; to cause circulatory, 
nutritive, and alterative changes in the soft tissues 
within reach-muscles, tendons, organs, etc. 
4. Tapotement (Tapping or Percussing).-(1) 
Clapping, used with palms of both hands. (2) 
Hacking, used with ulnar border of hands. (3) 
Pinctating or titillation, used with tips of fingers 
with a shoving motion. (4) Beating, used with 
clenched hand, with the ulnar edge, or with the 
knuckles. These manipulations are mainly used 
on muscular parts, as the back, back of legs, 
gluteal region, and well-developed subjects in 
general. 
It is well known that the circulation at the sur- 
face is not so active as that of the interior of the 
body; therefore in massage effleurage is applied 
first in order to warm the surface-to stimulate 
the blood and lymph changes, to remove the old 
epithelial scales, that the pores and sebaceous 
glands may be freed from matter which causes 
obstruction. The frictions which are next applied 
reach a little deeper. Petrissage goes below the 
skin and fat overlying the muscles, and reaches 
the muscular structures and deep-lying organs. 
Tapotement imparts its stimulus to the deepest 
structures. 
1$. Cream, 
Whey, 
Water, 
each, 5 j 
Sodium bicarbonate, gr. x 
Milk-sugar, 1 teaspoon- 
ful. 
This may be partially peptonized by adding ex- 
tract of pancreatin, or peptogenic milk powder, 
and allowing to stand in a temperature of about 
110° F. for 8 or 10 minutes. It should be given 
from a bottle every 2 hours, and as the child's 
digestive powers increase, the amount should be 
increased, and later milk substituted for the whey. 
No medicines internally are of any use in ma- 
rasmus, but any indications should be properly 
met, and it is well to begin the treatment by giv- 
ing, for 2 or 3 days, mercury in small doses to clear 
out the intestinal tract. 
1$. Mercury and chalk, gr. ij 
Sodium bicarbonate, \ , .. 
Sugar of milk, J ' 
Mix and make 12 powders, and give 1 every 2 
hours until 4 are taken, repeating daily for 
3 days, and giving every morning following 
about 1/2 a teaspoonful of magnesia dis- 
solved in milk or water. 
The child should be weighed regularly, as this 
is the only reliable means of judging as to its 
progress. See Infant Feeding, Milk (Modified). 
MAR JOLIN'S ULCER.-An epithelioma de- 
veloping from the edge of a chronic ulcer or an 
old scar. It is very painful and secretes a foul 
discharge. Late in its course the anatomically 
related lymph nodes become affected. Diagnosis 
may be made by excising a piece of tissue from 
the margin of the ulcer and examining it with the 
microscope. 
Treatment consists in free extirpation of the 
diseased area together with removal of the as- 
sociated lymph nodes; and, in advanced cases in 
which the diseased area is upon an extremity, 
amputation is demanded. 
MARRUBIUM (Hoarhound).-The leaves and 
tops of M. vulgare. They contain a bitter princi- 
ple, marrubiin, and a volatile oil. In small doses 
hoarhound is a mild stomachic tonic; in larger 
doses a laxative, diuretic, and diaphoretic. It 
exerts a soothing effect in catarrh of the nasal 
passages, and is, therefore, an ingredient of various 
cough mixtures. Dose, 20 to 60 grains. 
MARSH-FEVER.-See Malarial Fever, Malta 
Fever. 
MARSH-MALLOW.-See Althea. 
MASSAGE.-A method of effecting changes in 
the local and general nutrition, action, and other 
functions of the body by rubbing, kneading, and 
other manipulations of the superficial parts of the 
body by the hand or an instrument. A male 
operator is called a masseur, a female operator a 
masseuse. Persons skilled in massage should have 
a general knowledge of the superficial anatomy of 
the body and the position of the chief organs. MASSES 
MAXILLARY SINUS 
General massage is useful when the nutritive 
functions are to be extensively stimulated, when 
tissue changes in the different organs are to be 
promoted and the excretion of waste products in- 
creased. 
Local massage accelerates the circulation in the 
blood-vessels and lymphatics and greatly increases 
the nutrition in the parts, promotes excretion, 
makes muscles firmer, and increases muscular 
power. It is of especial value in infantile paral- 
ysis, in cases in which splints or supports have 
been worn for a long time, in hysteric affections of 
the joints and limbs, and in long-standing paralysis. 
Massage is applied to the abdomen in cases of 
atonic dyspepsia with flatulent distention. In 
constipation a course of kneading and rubbing 
throughout the length of the colon may lead to 
regularity of action, and is of especial value in 
cases of fecal accumulations. See Constipation. 
MASSES (Massae).-Pill masses are official under 
this name. There are two official masses: 
Massa Ferri Carbonatis.-100 gm. ferrous sul- 
phate; 46 gm. monohydrated sodium carbonate; 
38 gm. clarified honey; 25 gm. sugar; syrup and 
distilled water, each q. s. Dose, 4 grains. 
Massa Hydrargyri.-33 gm. mercury; 10 gm. 
glycyrrhiza; 15 gm. althaea; 9 gm. glycerin; 
honey of rose, 33 gm. Dose, 4 grains. See 
Pills. 
MASSOLIN.-A pure culture of the bacillus 
bulgaricus of Massol. The culture has the tend- 
ency to prevent the growth of pathogenic and 
pyogenic organisms. It is recommended in sup- 
purative conditions. 
MASTIC (Mastiche).-A concrete, resinous exu- 
dation from Pistada Lentiscus. Alcohol dissolves 
about 90 percent, including the resin, mastichic 
acid, the remainder consisting of another resin, 
mastichin, which is soluble in ether and resembles 
copal. There are no official preparations, but 
mastic is an ingredient of the official Pil. Aloes et 
Mastiches. Dose, 20 to 45 grains. 
Mastic was formerly used for supposed properties 
analogous to those of other oleoresins, but its 
application is now confined to dentistry, being 
employed as a temporary filling for carious teeth. 
A solution in ether is applied on cotton with 
moderate pressure, and remains as a firm plug 
after evaporation of the solvent. 
MASTITIS.-See Breast (Diseases). 
MASTOID DISEASE, AND OPERATION.-See 
Ear (Disease of Middle). 
MASTURBATION.-Production of the venereal 
orgasm by the hand. The evils arising from this 
habit have been generally exaggerated. With 
children, if there is any cause, such as an adherent 
prepuce, phimosis, or a very long foreskin, cir- 
cumcision will generally effect a permanent cure. 
The operation makes a distinct break in the habit, 
and, combined with close supervision and good 
moral treatment, complete emancipation may be 
obtained. In girls cleanliness of the genital organs, 
with close supervision, may remove the trouble. 
With older girls only moral treatment will be of use. 
The practice is often a symptom of mental de- 
ficiency or the first indication of psychologic disturb- 
ance, and has too often been regarded as the cause 
instead of the result of insanity. Moral treatment 
failing, mechanic methods, such as tying the hands 
after undressing at bedtime, arranging so that the 
patient does not sleep alone, or fastening a hard 
body, like an empty cotton-reel, over the spine, so 
that resting upon the back will be prevented, may 
be tried. Blistering the penis or labia is a severe 
measure, and, used alone, is not likely to be fol- 
lowed by any permanent benefit. Free purgation 
or regular emptying of the rectum, and the re- 
moval of thread-worms or anal irritation are not 
to be overlooked. Bad companions, filthy con- 
versation, and impure literature are to be avoided. 
Open-air exercise, pushed to fatigue; plain, un- 
stimulating food; and change of amusements and 
surroundings, will improve the physical tone. 
Drugs are not to be depended upon when there is a 
continual struggle between an unhealthy sexual 
appetite and a weakened will. Potassium bromid 
or sodium bromid, with potassium iodid and cold 
baths, are occasionally used with benefit. Blis- 
tering of the occiput and upper cervical spine may 
be occasionally useful in allaying excitability of the 
sexual centers. It is a question whether warnings 
against the evils of the practice, of which nothing 
is known, will prevent or promote indulgence in it. 
Such warnings must be most judiciously admin- 
istered to innocent and sensitive youths. 
MATCHES, Poisoning by.-See Phosphorus 
(Poisoning). 
MATICO.-The leaves of Piper angustifolium, 
containing a crystallizable acid artanthic acid, 
also resin, tannin, and a volatile oil. Its odor is 
aromatic, and its taste astringent, spicy and some- 
what bitter. Dose, 1/2 to 1 1/2 drams. 
Matico is an aromatic tonic and stimulant, also 
aphrodisiac, vulnerary and hemostatic. It acts 
like cubeb on the urinary passages, and is an ex- 
cellent alterative stimulant to mucous membranes. 
It has been used with considerable success in 
mucous catarrhs, as gonorrhea, leukorrhea, and 
chronic cystitis, also in epistaxis, hemorrhoids, 
menorrhagia, hemoptysis, hematemesis and other 
hemorrhages. The under surface of the leaf is so 
formed as to promote coagulation of blood if 
applied to a bleeding surface, and is a good local 
hemostatic for trivial cuts or wounds. 
Fluidextractum Matico.-Dose, 1/2 to 1 1/2 
drams. 
MATRICARIA.-The dried flower-heads of 
Matricaria chamomilla, German Chamomile. 
They contain 1/4 percent of a blue volatile oil, 
the color of which is due to azulen, also a bitter 
extractive, tannin, etc. There are no official 
preparations, but the flowers may be eaten or a 
decoction used almost ad libitum (average dose, 
4 drams). 
Matricaria is a mild tonic, in large doses emetic, 
anthelmintic and antispasmodic. It is much used 
in Germany, and in this country is a popular 
domestic remedy among German people, who 
use it in infusions as a diaphoretic. It is the 
chamomilla of the homeopaths. 
MAXILLARY SINUS.-See Nose (Accessory 
Sinuses). MAY-APPLE 
MEASLES 
MAY-APPLE.-See Podophyllum. 
MEAL, TEST-.-See Stomach-contents (Ex- 
amination). 
MEASLES (Morbilli; Rubeola).-An acute, in- 
fectious, highly contagious disease, characterized 
by a well-marked prodromal stage, with coryza 
and fever, followed by a characteristic eruption on 
the face and body. While probably due to a 
microorganism, the proof of this is wanting, as the 
specific germ has not yet been determined. 
Measles occurs in wide-spread epidemics, being 
most common in the spring of the year. It is 
contagious from the time of the beginning of 
catarrhal symptoms, being most contagious dur- 
ing this period and while the rash is coming out. 
With the fading of the eruption and subsidence of 
the catarrh the communicability diminishes. 
The duration of the infective period is about 3 
weeks, or as long as the patient is desquamating or 
the cough remains. Children of all ages over 6 
months are very susceptible to measles, and they 
usually contract it the first time they are fairly 
exposed to the contagion. Exceptions to this 
rule occur, some persons not having the disease, 
though exposed, until later life; others, not with- 
standing exposure, never contract it. 
One attack usually, though not always, confers 
immunity. Direct contact with a patient is usu- 
ally necessary, the infection seldom being car- 
ried by a third person, or in fomites, the poison 
not having the power to cling long to clothing or 
apartments, as does that of scarlet fever. 
The period of incubation is 7 to 14 days, and if 16 
days, at the longest, elapses after exposure with- 
out the disease developing, the person may be con- 
sidered safe from the attack. 
The pathologic lesions of measles consist of a 
superficial inflammation of the skin and a catarrhal 
inflammation of the mucous membranes, including, 
in some cases, besides the conjunctiva and upper 
and lower respiratory tracts, which are so con- 
stantly affected, those of the middle ear, intestinal 
tract, and vulva as well. Sometimes in severe 
cases a pseudomembranous exudate is present in 
the throat. 
Symptoms.-The prodromal or catarrhal stage 
is characterized by the symptoms of a "cold," 
with lacrimation and photophobia, coryza, and a 
hard bronchial or, sometimes, a croupy cough. 
The child is irritable and peevish. A somnolent 
condition is often present at this time, and in 
some cases a headache or earache is complained of. 
Rarely a convulsion marks the onset. The ton- 
sils and fauces are usually congested, but not so 
severely as in scarlet fever. The cervical lymph- 
glands are in many cases enlarged early. The 
temperature during this stage is elevated, varying 
from 100° to 104° F., which increases until the 
rash is fully developed. 
The symptoms mentioned, when occurring in a 
child, strongly suggest the probability of an attack 
of measles; and when on the second or third day 
there are seen on the hard palate papules of a dark 
purplish color, a diagnosis may safely be made 
without waiting for the eruption to appear upon 
the skin. 
Koplik's spots-which are characteristic, minute 
bluish-white spots on a reddish punctate area- 
may be observed on the mucous membrane of the 
cheeks and lips, in the preeruptive stage of mea- 
sles. They usually disappear when the skin erup- 
tion is at its height. The specks observed in 
thrush have a more yellowish center. 
The eruptive stage usually begins on the fourth 
day, the rash appearing on the neck, forehead, 
trunk, and extremities, in the order mentioned, 
taking about 4 days to spread over these parts. 
The eruption consists of small papules on a slightly 
reddened base, and is never vesicular or pustular 
in character. The surface is covered in patches, 
which sometimes assume a crescentic shape, be- 
tween which is seen the normal skin. The face, 
as a rule, is more generally covered than the other 
parts, and it has a swollen appearance, especially 
about the nose and eyes. 
The rash remains for from 1 to 6 days-4 days on 
the average-and begins to fade on the parts first 
affected, while it may still be appearing elsewhere. 
By the fifth or sixth day of the disease the fever, 
cough, and other symptoms subside rapidly (their 
continuance after the rash is fully out would indi- 
cate some complication), and by the eighth or 
tenth day after the beginning of the prodromal 
symptoms the eruption, except for a mottled dis- 
coloration of the skin, which may remain for a few 
days or a week, has entirely disappeared, and in 
favorable cases convalescence is rapid. Desqua- 
mation of a fine, branny nature is usually seen 
following the fading of the rash. 
The severity of measles markedly varies, some 
epidemics being quite uniformly of a mild, and 
others of a severe, type. Different individuals are 
also more or less severely affected, depending 
greatly upon the season of the year, the condition 
of the patient, and the surroundings and care. 
The severe cases occur more frequently among 
infants than among older children. In some in- 
stances there is no fever and the exanthem is 
trivial or even absent. 
Complications and Sequels.-Bronchopneumonia 
is the most common complication. Catarrhal or 
sometimes membranous laryngitis, chronically 
enlarged lymphatic glands which are apt to become 
tuberculous, catarrhal or purulent otitis media, 
conjunctivitis, endocarditis, vulvovaginitis, and, 
especially in the summer months, intestinal dis- 
orders, as enterocolitis, are quite frequent. 
Keratitis and severe conjunctivitis occur among 
poor children and may persist for a long time. In 
many cases the health of the child remains im- 
paired for a long time, and the danger of tuber- 
culosis following measles in a delicate child should 
be remembered. 
Diagnosis.-The fact that the patient has been 
exposed to the infection, or that there are other 
cases in the neighborhood, is always a valuable 
point in reaching a diagnosis in any of the con- 
tagious diseases. The marked coryza and dread 
of light, the erythema of the mouth and fauces, the 
presence of Koplik's sign, the quite uniform period 
of incubation, and the characteristics of the rash 
must all be considered. In certain mild or irregu- MEASLES 
MEATUS, URINARY 
Measles. 
Variola. 
Varicella. 
Scarlatina. 
Rubella. 
Incubation 
10 days 
12 days 
17 days 
4 days 
12 days or longer. 
Prodromes 
3 days. Coryza, 
cough, etc. Kop- 
lik's spots. 
3 days. Rigor, high 
fever, headache, 
lumbar pains. 
A few h o u r s or 
often none. Very 
slight. 
24 to 48 hours. An- 
gina, vomiting, 
rapid pulse, high 
fever. 
A few hours. Slight 
catarrh, etc.; usu- 
ally enlarged cervi- 
cal glands. 
Character of erup- 
tion. 
Bluish papules; 
swelling of face; 
discrete or con- 
fluent circular out- 
lines. 
Macules, papules, 
vesicles, and pus- 
tules; discrete or 
confluent. 
Vesicles, discrete... 
Erythema; scarlet 
color, confluent or 
punctate. 
Papules; discrete 
or confluent in 
patches; rosy 
color. 
Parts first affected. 
Forehead, face, or 
neck. 
Forehead 
Face, scalp, or 
shoulders 
Neck, face, and 
chest. 
Face. 
Desquamation.... 
Furfuraceous 
Large crusts 
Small crusts. 
Lamellar 
Slight, furfuraceous 
Duration 
7 to 10 days 
3 weeks 
1 week 
7 to 10 days 
1 week. 
Complications and 
sequels. 
Eye and lungs; 
tuberculosis. 
Larynx and lungs.. 
Kidney, ear, and 
heart. 
lar cases a concluson can be arrived at only after 
carefully weighing the symptoms as a whole. 
The foregoing table gives the principal points of 
difference in the eruptive diseases. See Exan- 
thems. 
The prognosis in healthy children, under favor- 
able surroundings, is good; but in tuberculous and 
wasted children, especially when there are serious 
complications and sequels, it may be of a grave or 
fatal character. Occurring before the fifth year, 
measles is a much more dangerous disease than 
after that age. 
Treatment.-Infants and weak children should 
be carefully protected from exposure to measles. 
The patient should be isolated in order to prevent 
the spread of the disease. He should be placed 
in a large, darkened, well-ventilated room, the bed 
being protected from drafts by a screen, and when 
the laryngeal symptoms are severe, the air in the 
room should be kept moistened with steam. The 
patient should be kept in bed until the tempera- 
ture has been normal for a week, and kept in the 
house for at least a week longer. Water or acidu- 
lated diunks, as weak lemonade, should be freely 
given, as the thirst is usually great. The diet 
during the febrile stage should be liquid, milk 
being the best. There are no remedies which will 
cut short the attack. The treatment is sympto- 
matic and directed toward making the patient as 
comfortable as possible and protecting against 
complications. When the case is first seen, an 
enema or a mild laxative, such as castor oil, to 
act upon the bowels, is beneficial, being careful, 
owing to the irritability of the intestinal tract, not 
to produce too marked an effect in this direction. 
For the bronchial cough and the fever, the fol- 
lowing mixture is very useful: 
When there are nervous symptoms, manifested 
by headache, restlessness, etc., phenacetin or ace- 
tanilid, 1/2 grain for each year of the child's age, 
given every 3 or 4 hours, will give relief. 
The eyes should be bathed 2 or 3 times a day 
with a solution of boric acid (10 grains to the 
ounce) or with the following: 
R. Mercuric chlorid, gr. 1/100 
Zinc phenolsulphonate, gr. iij 
Boric acid, 
Sodium chlorid, 
each, gr. xv 
Aqueous extract of hama- 
melis, 5 v 
Camphor-water, 
Distilled water, 
each, o jss. 
Vaselin rubbed on the edges of the lids in the 
evening will prevent the eyelids from becoming 
glued together during the night. 
For the coryza: 
I). Menthol, gr. x 
Liquid albolene, 3 j. 
Apply 2 or 3 times a day in the nares with an 
atomizer or with a piece of cotton wrapped 
on a probe. 
From the beginning of the attack until desqua- 
mation has ceased, a warm bath (95° to 100° F.), 
followed by inunctions of cacao-butter, should be 
given daily; and when the temperature is high, 
sponging the body with cool or tepid water and 
alcohol, as in other febrile affections, may be 
safely practised. 
The period of convalescence should be carefully 
watched, and the child allowed plenty of fresh air, 
but should be guarded against exposure to cold or 
damp weather. 
Creosote and cod-liver oil should be given when 
there is a tendency to tuberculosis or when a cough 
remains. 
MEASLES, GERMAN.-See Rubella. 
MEASURES.-See Weights and Measures. 
MEAT.-See Beef. 
MEATUS, URINARY.-See Urethra 
R. Potassium citrate, 5 iv 
Lemon-juice, 3 j 
Camphorated tinc- 
ture of opium, 
Syrup of ipecac, 
each, 5 ij 
Syrup of tolu, q. s. 3 iij. 
Give 1/2 to 1 teaspoonful every 2 or 3 hours. MEDIASTINUM, DISEASES 
MEDICINES, ADMINISTRATION 
MEDIASTINUM, DISEASES.-The mediastinum 
is the space in the thorax between the pleural sacs, 
divided into 2 parts: the anterior, situated before, 
and the posterior, behind, the heart. In the 
anterior mediastinum are the remains of the thy- 
mus gland and the origins of some of the hyoid 
and laryngeal muscles. It is narrowed at the 
center, and in the lower part there is some areolar 
tissue, together with the left triangularis sterni 
muscle. The posterior mediastinum is larger than 
the anterior, and contains the aorta, the vena 
azygos, the thoracic duct, the esophagus and its 
nerves, the trachea, the splanchnic nerves, and 
some lymphatic glands. A middle mediastinum is 
sometimes described, containing the heart and the 
origin of its great blood-vessels, with the bifurca- 
tion of the trachea. 
Emphysema of the mediastinum is the presence 
of air in the cellular tissue thereof, and sometimes 
exists apart from emphysema of the neck. It has 
been found in fatal cases of diphtheria in which 
tracheotomy has been performed. 
Inflammation of the mediastinum gives rise to 2 
prominent symptoms: dyspnea and severe pain 
referred to the poststernal region. Physical exam- 
ination does not render much aid in diagnosis. 
In most cases of abscess in the anterior mediasti- 
num some history of a cause is obtainable. If not, 
it is very difficult to distinguish between it and an 
aneurysm. 
Surgical treatment, to open the abscess and 
establish drainage, is imperative. The inflamma- 
tory action is liable to spread, and to involve the 
lungs or the pericardium. 
New Growths.-Almost every form of morbid 
growth has been encountered in the mediastinum- 
cancer, sarcoma, osteosarcoma, enchondroma, 
lymphadenoma, fibrous tumors, steatoma, larda- 
ceous and tubercular masses, and syphilitic 
gummata. The growth of some is more rapid 
than that of others, and constitutional symptoms 
are more pronounced in some than in others. 
The duration of malignant intrathoracic growths 
is rarely more than a year. The more prominent 
symptoms are the cardiac, and the development 
is inward rather than outward, and only rarely do 
the chest-walls become eroded. Derangements of 
the circulation give rise to phenomena of diagnostic 
importance. It is not from pressure alone, but 
also from involvement of the vessels themselves, 
that the symptoms arise. Hemoptysis, san- 
guineous effusion into the pleura, and infarcts are 
frequent. Febrile disturbances are not marked, if 
at all present, at any time. Disturbances of 
innervation vary in severity and in character. 
Neuralgic pains are very common. Cough is 
either reflex or from bronchial irritation. Respi- 
ratory phenomena range from paroxysms of 
dyspnea to orthopnea. 
Treatment.-Palliation of the most urgent 
symptoms is demanded. Bodily rest, freedom 
from moral disturbances, maintenance of general 
nutrition, change of air and hygienic conditions, 
are essential. Certain symptoms call for special 
treatment, such as counterirritation, sinapisms, 
and small blisters for pain. Opium, chloral, potas- 
sium bromid, and minute doses of antimony may 
alleviate the distress. Chlorodyne, Hoffmann's 
anodyne, and chloroform inhalations are often 
useful. Paracentesis may be resorted to, and 
iodin, chalybeates, and other constitutional 
methods may be employed. 
MEDICINES, ADMINISTRATION. - Medicines 
may be introduced into the circulation by various 
routes, including the mouth, the stomach, the 
rectum, the respiratory tract, the veins and 
arteries, the subcutaneous cellular tissue, and the 
integument. 
The mouth is the usual receptacle for medicines 
intended for the stomach, but may itself be em- 
ployed for the introduction of minute quantities 
of powerful agents. A drop of the tincture of 
aconite placed on the tongue is quickly absorbed 
and soon manifests that fact by its symptoms. 
Many of the small tablets used for hypodermic 
administration, if placed under the tongue, are 
readily conveyed into the system, and, used in 
this way, form a very convenient means of medica- 
tion with alkaloids and other active principles. 
The stomach is the most convenient organ for 
the absorption of medicines and the one most fre- 
quently employed. After having been swallowed, 
the remedies find their way into the current of 
the circulation through the walls of the gastro- 
intestinal blood-vessels and the lacteals. When 
the stomach is empty and its mucous membrane 
healthy, crystalloid substances in solution pass 
rapidly through the walls of its vessels. Colloid 
substances (fats, albumin, gum, gelatin, etc.) 
require to be digested and emulsified before they 
can be absorbed. lodin and iodids should be given 
on an empty stomach, so that they may diffuse 
rapidly into the blood; if administered during 
digestion, the acid gastric juice and the starch of 
the food will alter their chemic constitution and 
weaken their action. Acids should be given, as a 
rule, on an empty stomach, especially when they 
are intended to check the secretion of the acid of 
the gastric juice. Alkalies, of which sodium bi- 
carbonate may be taken as the type, are given 
after meals to neutralize excessive acidity, and be- 
fore meals to stimulate the acid gastric secretions. 
Silver oxid and silver nitrate should be administered 
after the digestive process is ended; if given during 
digestion, chemic reactions destroy or impair their 
special attributes and defeat the object for which 
they were prescribed. Metallic salts (especially 
corrosive sublimate), also tannin and pure alcohol, 
impair the digestive power of the active principle 
of the gastric juice, and should only appear in the 
stomach during its period of inactivity. Malt 
extracts, cod-liver oil, phosphates, etc., should be 
given with or directly after food, so that they may 
enter the blood with the products of digestion. 
Bismuth should be given before meals, as it is 
usually employed for its local sedative action on 
the gastric mucous membrane. Potassium per- 
manganate should be given after meals, for in an 
empty stomach it would irritate the mucous mem- 
brane and might possibly produce ulceration there- 
of. Arsenic, and other irritant and dangerous 
drugs (the salts of copper, zinc, and iron), should MEDICINES, ADMINISTRATION 
MELANODERMA 
be given directly after food, except when local 
conditions require their administration in very 
small doses on an empty stomach. Morphin by 
hypodermic injection should only be given when 
the patient is lying down, unless previously 
habituated to its use. Pilocarpin, administered 
to produce sweating, should be given when the 
patient is in bed in a warm room. Ammonium 
acetate acts as a diaphoretic when the recipient is 
warm in bed, but as a diuretic when the patient is 
in a cold atmosphere. Sulphonal should be given 
2 or 3 hours before its hypnotic action is desired, 
as it is very slow of solubility and absorption 
(Potter). 
Under some circumstances it becomes necessary 
to introduce medicines directly into the stomach, 
as in case of the patient's inability to swallow, 
through narcotic poisoning or other causes. The 
stomach-pump or the stomach-tube may then be 
employed to convey both food and medicine to 
that organ. In obstruction of the esophagus, as 
from stricture or malignant disease, it may become 
necessary to make an opening through the ab- 
dominal wall and the wall of the stomach itself. 
Nasal feeding, by the use of a soft catheter with a 
hard-rubber funnel inserted into its end, is a very 
efficient method of conveying liquids into the 
stomach. The eye end of the catheter is oiled and 
passed gently along the floor of the nose and down 
the pharynx, the fluid being then poured into the 
funnel. In many cases, especially insane ones, the 
patient will so constrict the muscles of the throat 
as to force the catheter into the mouth; but if it is 
withdrawn until nearly out of the pharynx, the 
presence of the fluid as it drops down will excite 
swallowing, and the patient may be fed as well as 
if the tube were in the esophagus. This method is 
particularly serviceable in cases of acute tonsillitis 
or other painful affections of the mouth and palate, 
also after excision of the tongue, when swallowing 
is to be avoided as much as possible. See Gavage. 
The rectum will absorb many substances ap- 
plied in the form of enemata or suppositories. 
Those most suited to this route are the salts of the 
alkaloids in solution, especially those of morphin, 
atropin, and strychnin, the latter being absorbed 
more rapidly by the rectum than by the stomach. 
Acid solutions, if not too frequently repeated, are 
well administered by this channel. Nutritive 
enemata must be small, not exceeding 3 or 4 fluid- 
ounces, or they will not be retained. They be- 
come necessary in many cases, especially in cases 
of gastric ulcer, in order to afford rest to the stom- 
ach. It is often found advantageous to have the 
food predigested before being administered by the 
rectum, for which purpose pancreatin is used. 
See Suppository, Enema. 
The respiratory tract admits of the rapid absorp- 
tion of medicinal substances through its extensive 
blood-supply. The inhalation of vapors or atom- 
ized fluids, the insufflation of powders into the 
nares, fauces, larynx, etc., and the use of a medi- 
cated nasal douche, are methods whereby this 
channel may be utilized. See Inhalant, Hypo- 
dermic Medication, Intravenous Injection, 
Inunction, etc. 
MEDULLARY ANESTHESIA.-See Intra- 
spinal Anesthesia. 
MEGRIM.-See Migraine. 
MEL (Honey).-The substance deposited in the 
honeycomb by the common honey-bee, Apis mel- 
lifica, and a few other hymenopterous insects. It 
consists of a solution of cane-sugar and grape- 
sugar, with coloring and odorous matters. It is 
emollient, nutritive, and often laxative, its prop- 
erties depending mainly on the character of the 
flowers from which it is taken. It is an excellent 
vehicle for expectorant gargles, etc. In pharmacy 
mellita, or honeys, are thick liquid preparations 
closely allied to syrups, but having honey as a 
base. There are three official honeys: Mel. Mel 
Depuratum, clarified honey, prepared by heating, 
skimming, and straining the natural product. 
M. Rosae, honey of rose; fluidextract of rose 120, 
clarified honey to 1000. It is used locally as a gargle. 
MELANCHOLIA.-A form of insanity character- 
ized by depression of spirits and gloominess, 
without any adequate cause, the central idea being 
one of personal unworthiness. As the case de- 
velops, delusions, associated with illusions and 
hallucinations, appear, and the patient may at 
times show suicidal tendencies. The general 
nutrition suffers, and in females menstruation is 
usually suppressed. The usual age at which melan- 
cholia appears is during middle life. It follows 
any depressing cause, acting in conjunction with a 
strong hereditary tendency. It usually termi- 
nates in recovery, but some cases develop into 
dementia or mania, while others die from exhaus- 
tion or commit suicide. 
Treatment.-It is generally useless to argue with 
a patient about the folly of his delusions or hallu- 
cinations. Removal of the condition of the brain 
upon which the morbid feeling depends is impor- 
tant. The first indication is to improve the 
general health and restore the exhausted nerve 
force by fresh air, good food, and tonics. Foreign 
travel is often highly efficacious, but a quiet rest 
at a health resort is as beneficial in most cases. 
Removal to an asylum is often productive of great 
benefit, the orderly, settled life and discipline 
being efficacious. Refusal to eat is often difficult 
to treat. It may be necessary to resort to forcible 
feeding 2 or 3 times daily with milk, meat-extracts, 
liquid custards, etc. Attention to the gastro- 
intestinal canal is of the greatest value, as the 
dyspepsia and constipation of melancholic patients 
are the greatest barriers to their recovery. Fre- 
quent bathing, with friction to the surface, aids in 
the eliminative action of the skin. Such tonics as 
quinin sulphate, arsenic, iron, and strychnin 
sulphate are all of value in building up the pa- 
tient. As the strength improves, open-air exercise 
must be added to the other means used. Insom- 
nia must be combated by evening bathing and 
feeding, and the use of trional, sulphonal, or 
hyoscin at bedtime. When stupor is present, the 
effect of the continuous electric current is often 
markedly beneficial. 
MELANEMIA.-See Blood. 
MELANODERMA or MELASMA.-See Chloas- 
ma, Suprarenal Disease. MELENA OF THE NEW-BORN 
MENINGITIS 
MELENA OF THE NEW-BORN.-A greater or 
less amount of blood in the stools of children is 
not rare, and its presence may be due to blood 
having been swallowed with the milk, or from le- 
sions in the nose, mouth, or throat. It may come 
from the large intestine, as in dysentery, when it is 
red and fluid, or from an ulcer of the stomach or 
small intestine, when it is black and tarry in ap- 
pearance. True melena of the new-born, however, 
is a rare disease. It is more common in hospital 
cases than in private practice, occurs the first 2 
weeks of life, usually the second or third day, is 
apparently self-limited, when recovery takes 
place, the course being 5 to 9 days, and after death 
no lesion may be found in the gastrointestinal 
tract to account for the hemorrhage. For these 
reasons it is thought to be of an infectious 
nature, but further than this the etiology is not 
known. 
Symptoms.-When the hemorrhage is consider- 
able, the child will become suddenly pale and 
present the symptoms of collapse. The bowel 
movements will consist of thick, dark blood, and 
may follow one another in rapid succession, the 
later ones consisting of bright blood. When the 
amount of blood lost is slight, it may be dis- 
covered only when the napkin is changed, and the 
little patient will retain a normal appearance. A 
rise in temperature (101° to 103° F.) during the at- 
tack has been noticed in all cases. The hemor- 
rhage may recur for several days, and the child is 
worn out by the excessive loss of blood and be- 
comes emaciated and dies, or, when recovery takes 
place, convalescence is likely to be long and trouble- 
some. The mortality rate is given as 50 to 80 
percent. 
Treatment.-Food should be given cold. The 
infant must be kept absolutely at rest, and if 
the body and extremities are cold, hot-water 
bottles should be placed about it. Morphin in 
minute doses, 1/1000 to 1/500 of a grain hypo- 
dermically, or 1 drop of paregoric by the mouth, 
may be necessary to quiet the child. One-drop 
doses of spirits of turpentine suspended in mucilage, 
given every hour, seem to have a controlling in- 
fluence on the hemorrhages. 
In other cases 1-drop doses of chlorid of iron 
have given good results. Ergotin, in 1/2 grain 
doses by the mouth or hypodermically, should be 
tried. 
MEMORY, LOSS.-See Amnesia. 
MENIERE'S DISEASE.-The symptom com- 
plex known as Meniere's disease is probably the 
result of a morbid process in the labyrinth or 
auditory nerve endings. It is characterized by 
excessive vertigo, loud tinnitus aurium, nausea, 
vomiting, and other phenomena. The symptoms 
appear at first in distinct paroxysms, ushered in by 
a shrill ringing in one ear, followed by pronounced 
dizziness. Consciousness is impaired; the skin is 
pale and cool, and the face is bathed in cold per- 
spiration. The first paroxysms are of brief dura- 
tion, but they may persist for years until overcome, 
or deafness is complete on that side. 
This affection is not to be confounded with 
epilepsy or apoplexy. The sudden onset of the 
paroxysm, and the complaint of vertigo, together 
with ear symptoms, lead to a certain diagnosis. 
Treatment.-The following remedies have been 
used: Quinin, 5 to 10 grains; bromids, 30 grains; 
salicin or salicylates, 30 grains; digitalis, 10 
minims of the tincture every 4 or 8 hours, 
along with counterirritation behind the mastoid, 
and by the continuous current. Pilocarpin, 1/8 
grain or less, and ammonium bromid with ammo- 
nium chlorid, 15 grains of each, have given relief. 
Sometimes air charged with chloroform vapor, 
injected into the eustachian tube, dispels the dis- 
comfort. 
MENINGITIS.-Inflammation of the membranes 
of the brain. The several varieties are considered 
below; and see Cerebrospinal Meningitis. 
Inflammation of the dura; when the external 
layer is primarily involved, it is termed external 
pachymeningitis; when the internal layer is 
primarily involved, it is termed internal pachy- 
meningitis. 
Etiology.-External pachymeningitis is a surgical 
malady, induced by fractures, penetrating wounds, 
and other injuries of the skull. Internal pachy- 
meningitis is due to blows upon the head without 
injury to the skull. A predisposition may be 
created by chronic alcoholism, scurvy, nephritis, 
and syphilis. Chronic internal otitis and suppura- 
tive inflammation of the orbit, and inflammation in 
the venous sinuses, the result of a thrombus 
undergoing suppurative changes, may be causes. 
The symptoms are very obscure, and are princi- 
pally those of cerebral pressure. Persistent 
headache, vertigo, photophobia, anorexia, in- 
somnia, gradual impairment of intellect and loco- 
motion, followed by delirium and convulsions and 
coma, or by apoplectic attacks and paralysis, 
are suggestive signs in the aged, or those in whom 
some one of the causes of pachymeningitis is 
present. Circumscribed painful edema behind 
the ear and less fulness of the jugular of the cor- 
responding side are indicative of thrombosis in the 
transverse sinus. 
Diagnosis is always problematic, as the symptoms 
are masked. 
Prognosis is most unfavorable for either form, 
although the course of the malady is usually slow. 
Surgical treatment in traumatic cases offers some 
hope. 
Treatment.-External pachymeningitis should 
be treated surgically. Trephining is indicated in 
some cases. It is claimed that benefit has fol- 
lowed a thorough course of potassium iodid. In 
the great majority of cases, however, all that can 
be done is to treat the distressing symptoms. 
See Brain (Inflammation). 
Pachymeningitis. 
Simple Acute Meningitis. 
Under simple acute meningitis are classed those 
cases of inflammation of the pia not due to a 
specific organism, such as the tubercle bacillus. 
The affection is most common in children. 
Etiology.-Meningitis may follow traumatism 
of the skull and sunstroke. It also occurs second- MENINGITIS 
MENINGITIS 
ary to the infectious diseases, such as pneumonia, 
scarlet fever, variola, influenza, acute nephritis, 
or rheumatism, and may result from purulent 
otitis media, caries of the small bones of the skull, 
or erysipelas of the head. Some cases are idio- 
pathic, the cause not being apparent. 
Pathology.-The cerebrospinal fluid is increased 
in quantity, and there is an inflammatory condition 
of the pia, also of the dura and the gray matter of 
the brain. When the disease continues for a con- 
siderable length of time the membranes become 
thickened, and the pia becomes adherent to the 
cortical substances. The inflammation may be 
nonpurulent, but in severe cases pus is found in 
the pia, the subarachnoid spaces, and over the 
convolutions of the brain. When recovery takes 
place the exudate is absorbed, but the membranes 
may remain thickened and adherent. 
Symptoms.-The disease usually comes on 
gradually, and is indicated by a feeling of malaise, 
headache, nausea, and vomiting, which symptoms 
may continue for several days. The vomiting 
occurs independently of taking food, and, although 
it is so persistent, it may be associated with a 
clean tongue. The bowels are, as a rule, consti- 
pated. The patient becomes listless, apathetic, 
and drowsy, and may have a convulsion. Later, 
there are restlessness, delirium, and, finally, coma; 
the back of the neck is stiff, and there may be 
opisthotonos, repeated convulsions, or paralysis. 
The eyes are set, and optic neuritis may give rise 
to blindness. There is loss of control of the blad- 
der and rectum. The temperature varies from 
101° to 104° F., but there may be hyperpyrexia 
(106° or 107° F.). The pulse, which at first is very 
rapid, becomes irregular and slow. In unfavor- 
able cases the symptoms all increase in severity; 
the coma is deepened, and the respiration becomes 
of the Cheyne-Stokes character, ending in death. 
On the other hand, when recovery is to take place, 
the symptoms remain stationary for a time after 
the comatose stage is reached, then gradually 
abate, and consciousness and improvement slowly 
follow. 
The course of the attack is from 4 to 12 weeks. 
The prognosis is always grave, and when re- 
covery occurs, there are frequently left traces of 
the disease, such as blindness, paralysis, speech- 
defects, or a defective intellect. 
Diagnosis.-It is important not to confound 
true meningitis with the pseudomeningitis, which 
is a purely nervous or toxic condition, occurring 
with digestive disturbances or with the infectious 
diseases, as influenza, pneumonia, or the exan- 
thems, and which in children so frequently give 
rise to grave cerebral symptoms. 
Tubercular meningitis is differentiated by the 
fact that in this affection there are usually pro- 
dromes, intermissions in the temperature, an 
irregular course, perhaps a longer duration, and a 
greater tendency to coma. The family history 
and diathesis of the child will give valuable infor- 
mation. An error is easily made, however, in 
these cases, and the prognosis must therefore be 
guarded. 
In cerebrospinal meningitis the onset is more 
sudden, the course shorter, there may be an erup- 
tion on the skin, and it usually occurs in more or 
less wide-spread epidemics. See Cerebrospinal 
Meningitis. 
When the diagnosis is at all doubtful, lumbar 
puncture should be resorted to. 
Treatment.-The patient should be kept in a 
darkened, absolutely quiet room, attended by a 
careful and intelligent nurse, and given at first a 
purgative dose (1 to 5 grains, repeated if necessary) 
of calomel, continuing with smaller doses (1/10 to 
1/2 grain) every 3 or 4 hours. Since urotropin 
seems to have an antiseptic action on the cerebro- 
spinal fluid, its administration is advocated in 
beginning meningitis or when meningeal infection 
is feared as a complication. To protect against 
the action of the mercurial, the mouth should be 
frequently washed with a solution (5 to 10 grains to 
the ounce) of chlorate of potassium. The hair 
should be cut short, and an ice-bag kept applied 
to the head. For the restlessness and wakefulness, 
a warm bath or sponging with warm water will 
often have a quieting effect but if not, chloral and 
the bromids, sulphonal, or trional must be used. 
Large doses of the bromids (10 to 15 grains every 
2 hours for a child 2 years old) may be necessary 
before the desired result will be secured. 
The following formula will be found a convenient 
combination: 
3. Chloral hydrate, 5 ss 
Sodium bromid, 
Sodium iodid, 
each, 5 ij 
Water, g iv. 
One teaspoonful in water every 3 hours to a 
child 3 or 4 years old. 
If the treatment outlined above does not lessen 
the severity of the symptoms, alternate lukewarm 
and cold douching of the neck and upper part of 
the spine should be practised 3 times a day, and 
inunctions of mercury thoroughly applied twice a 
day. For the relief of severe pain, it may be 
necessary to give morphin (1/24 to 1/4 of a grain) 
hypodermically. When the pulse is rapid, irregu- 
lar, or weak, alcohol in some form and digitalis are 
called for. Retention of urine may occur, when it 
will be necessary to use the catheter; and when 
there is refusal or inability to take food, the 
patient must be fed by gavage or by the rectum. 
For the paralysis which may remain after the 
attack, massage, warm baths, and friction should 
be employed, but electricity only after all symp- 
toms of central irritation have subsided. lodid 
of potassium should be given for a long period 
when the symptoms persist, as it aids the absorp- 
tion of inflammatory products. Lumbar punc- 
tures have proved beneficial. 
Synonyms.-Tuberculous leptomeningitis; basi- 
lar meningitis; acute hydrocephalus, water on the 
brain. 
An inflammation of the soft intracranial mem- 
branes, more particularly the basal pia mater, 
attended with or due to the deposit of gray miliary 
Tuberculous Meningitis. MENINGITIS 
MENINGOMYELOCELE 
tubercles; characterized by gradual decline of the 
bodily and mental powers. 
Etiology.-It is usually a secondary affection, a 
sequel to tuberculous disease of some other organ. 
It occurs most frequently in children between 2 
and 6 years of age, although numerous cases are 
reported between the ages of 20 and 30. The so- 
called scrofulous children possess a special sus- 
ceptibility to tubercular meningitis. 
Pathologic Anatomy.-The deposition of tuber- 
cle usually occurs at the base of the brain. Depo- 
sitions of grayish-white granules, of a translucent, 
somewhat gelatinous appearance-miliary tubercle 
-are distributed along the vessels of the pia 
mater, resulting in inflammation and the exuda- 
tion of lymph, with the consequent thickening and 
opacity of the membranes. The cerebral tissue is 
not usually involved, although on section the lines 
indicative of blood-vessels are very much increased 
in number. The ventricles are distended by a clear 
or milky, or even bloody, serum. Tubercular 
deposits occur in the lungs, intestines, and, at 
times, in other organs. The presence of the tuber- 
cles alone may give rise to no symptoms until the 
exudative products of the resultant inflammation 
develop. 
Symptoms.-The advent is either gradual and 
insidious, or with convulsions, in which case the 
after-progress is rapid. 
Prodromes.-The child grows irritable, with loss 
of appetite, loss of flesh, swollen abdomen, consti- 
pation alternating with diarrhea, irregular attacks 
of feverishness, grinding the teeth during sleep, or 
insomnia. The child exhibits symptoms of head- 
ache. The duration of this stage is from 1 week to 
a month or two. 
Stage of Excitation.-The onset is somewhat 
sudden, with obstinate vomiting, severe headache, 
convulsions, fever, 102° to 103° F. in the evening, 
falling to 99° F. in the morning, pulse soft and 
compressible, with irregular rhythm. On drawing 
the finger-nail lightly over the surface, a red fine 
results. The symptoms grow progressively worse 
with exaltation of the special and general senses, 
the least pinch or even touch causing exquisite 
pain; there are spasmodic movements of the 
muscles with contraction and rigidity, and at 
times even opisthotonos. The duration of this 
stage is about 2 weeks. 
Stage of Depression.-The symptoms of this stage 
are the result of the pressure of the exudation. 
The pulse is slow and compressible, with irregular 
rhythm; the temperature is depressed; there is a 
tendency to somnolence alternating with quiet 
delirium, mental stupor, and continual movement 
of the fingers, as in picking up objects. From 
time to time convulsions appear with strabismus, 
oscillation of the eyeballs, followed by intervals of 
wakefulness, when the headache is excruciating, 
causing the peculiar, shrill shriek-"the hydro- 
cephalic cry," associated with contraction of the 
muscles of the face, as if suffering were experienced. 
Finally collapse occurs, with the Cheyne-Stokes 
respiration, the coma deepening, followed by 
death, convulsions often ending the scene. The 
duration of this stage is from 1 day to 2 weeks. 
Diagnosis.-Simple acute meningitis and tuber- 
cular meningitis have closely analogous symptoms 
during the stage of excitation, but the history and 
clinical course of the two maladies determine the 
diagnosis. 
Prognosis is unfavorable. The usual duration is 
3 or 4 weeks after fully developed prodromes. If 
ushered in by convulsions, the duration is shorter. 
Treatment is unsatisfactory. There are no 
means of retarding the disease. The symptoms 
should be treated as they develop. Blisters, 
leeches, active purgation, pustulating ointments, 
potassium iodid, and mercury are all useless. 
Lumbar puncture has been praised highly by 
some. 
If the hereditary tendency is marked, nutritious 
food, cod-liver oil, iron iodid, and quinin may be 
used in prophylaxis and treatment. See Tuber- 
culosis. 
MENINGOCELE.-A meningocele is a congeni- 
tal hernia protruding through an opening of the 
skull. When, in addition to the meninges, the 
brain-substance protrudes, it is termed encephalo- 
cele, and when this mass also contains liquid, 
hydrencephalocele. 
The most frequent site of these tumors is at the 
occiput, when the protrusion occurs from an open- 
ing through or at the edge of the occipital bone; the 
next most common location is the nasofrontal re- 
gion; they are rarely seen on other portions of the 
skull. 
Symptoms.-The tumor varies in size from a 
mere nodule to a size as large or larger than the 
rest of the child's head, and whatever the exact 
character of its contents, it can be more or less 
reduced by compression, but such compression 
usually produces cerebral symptoms, such as stupor 
or fretfulness, vomiting, and strabismus. The skin 
covering the tumor may be tense and covered with 
a scant growth of hair, or red and vascular. 
Diagnosis.-An encephalocele pulsates, and, 
when the child cries, becomes tense; it is usually 
opaque, and indistinct fluctuation may be felt. 
A true meningocele is always small, and, as a rule, 
pedunculated; its contents admit of complete re- 
duction, and it is translucent. 
Prognosis.-The occipital tumors are usually 
more serious than the frontal ones. In the major- 
ity of cases death occurs during the first few weeks 
of life, the result of meningitis, convulsions, or 
rupture, and when death does not take place, 
most of the patients exhibit signs of mental im- 
pairment or other evidences of organic brain- 
disease. 
Treatment.-The growth should be carefully 
protected from injury, operation being justifiable 
only in case of impending rupture. Repeated 
tappings and injection of Morton's fluid (iodin, 10 
grains; iodid of potassium, 30 grains; glycerin, 1 
ounce) have succeeded in cases of meningocele in 
reducing the tumor, but unless it is pedunculated 
and very small, the probability of a good result is 
very remote. See Spina Bifida. 
MENINGOCOCCUS SERUM.-See Cerebro- 
spinal Meningitis. 
MENINGOMYELOCELE.-See Spina Bifida. MENOPAUSE 
MENTHOL 
MENOPAUSE.-The period at which menstrual 
activity ceases. This usually occurs beween the 
fortieth and fiftieth years. 
The final cessation of menstruation may occur in 
one of several ways: it may cease abruptly, there 
may be a gradual diminution in the amount of 
blood lost at each successive period until it finally 
ceases entirely, or there may be a gradually length- 
ening interval between the periods. Besides the 
cessation of menstruation there are other phe- 
nomena, such as disturbances of digestion, flushes 
of heat, and nervous derangements. These dis- 
turbances may be entirely absent or they may last 
for a period varying from a few months to 2 years. 
Associate symptoms of beginning presbyopia 
must not be overlooked. Return of bleeding 
after it has once ceased, or profuse bleeding at the 
time of the menopause, should always arouse 
suspicion in the mind of the physician. It is fre- 
quently caused by malignant disease of the uterus, 
fibroid tumors or fungous endometritis. 
The treatment of the menopause consists in 
attention to the general health and regulation 
of the bowels and diet. Plenty of fresh air 
and a proper amount of exercise will be found 
beneficial. For the nervous symptoms, change of 
surroundings and nerve sedatives are indicated. 
Saline purgatives are especially beneficial. The 
influence of beginning presbyopia in causing head- 
aches should be considered, and reading glasses 
ordered. The other reflex phenomena are best 
treated with potassium bromid, which drug also 
diminishes the amount of blood determined to the 
sexual organs. Occasional bleeding or cupping 
gives relief. Diet should be plain and unstimulat- 
ing, beer and spirits prohibited, and light wines 
allowed. Tepid baths are useful. Late hours 
are to be avoided. Abstracting blood from the 
uterus generally does harm, but leeches to the anus 
are sometimes beneficial. 
MENORRHAGIA AND METRORRHAGIA.- 
By the first term is meant profuse or excessive 
bleeding at the menstrual periods. By the second 
is meant bleeding between the menstrual periods. 
Menorrhagia is a relative term, since the dura- 
tion of the menstrual period and the amount of 
blood lost at each period vary so widely in differ- 
ent women. To judge of this condition, therefore, 
in any particular case the present menstrual condi- 
tion must be compared with the previous men- 
strual history. 
The causes, pathology, and treatment of the fore- 
going conditions are practically the same. 
The most important causes are endometritis, 
subinvolution and displacements of the uterus, 
lacerations of the cervix, fibroid tumors, and tubal 
and ovarian disease. Endometritis is present in 
the great majority of instances, either alone or 
associated with one of the above conditions. 
After the age of 30, cancer of the cervix or of the 
body of the uterus should always be suspected. 
The treatment will depend upon the cause. 
Cancer and fibroid tumors usually require hysterec- 
tomy. Lacerations of the cervix should be re- 
paired, and displacements should be corrected by 
pessary or operation. Salpingo-oophorectomy will 
be necessary in the majority of cases due to chronic 
disease of the tubes and ovaries. 
Thorough curettage will relieve, temporarily at 
least, a large proportion of cases. Rest in bed, 
copious vaginal douches of hot water, glycerin 
tampons, and moderate purgation are all beneficial. 
Hydrastis, viburnum, and ergot are the drugs 
which have given the best results in the above 
cases. Thyroid extract has been used with success. 
The following formula will be found useful: 
T$. Fluidextract of ergot, 3 ij 
Fluidextract of hydrastis, 
Fluidextract of viburnum, 
each, 3 j. 
One teaspoonful in water 3 times a day. 
MENSTRUATION.-A periodic discharge of a 
sanguineous fluid from the uterus and fallopian 
tubes, occurring during the period of a woman's 
sexual activity, from puberty to the menopause. 
It is suspended during pregnancy and early lacta- 
tion. The flow is alkaline and composed of blood, 
shreds of mucous membrane, and vaginal and uter- 
ine secretion; it is darker than ordinary blood, and 
should not clot; its odor is characteristic and disa- 
greeable; the usual quantity is from 4 to 6, ounces. 
For discussion of the anomalies of menstruation, 
see Amenorrhea, Dysmenorrhea, Menopause, 
Menorrhagia and Metrorrhagia, Pregnancy, 
MENTAL DISEASES.-See Insanity. 
MENTHA PIPERITA (Peppermint).-The dried 
leaves and flowering tops of M. piperita, or common 
peppermint, having properties due to a volatile oil, 
in which form it is commonly used. It is an aro- 
matic stimulant, carminative, and antispasmodic, 
and is valuable internally to relieve flatulent colic, 
and externally to relieve superficial neuralgia. 
M. Pip., Aqua, contains 2 parts of the oil in 1000 
of distilled water. Dose, 2 to 6 drams. M. Pip., 01., 
the volatile oil. Dose, 1 to 5 minims. M. Pip., Spt., 
essence of peppermint, contains 10 percent of the 
oil and 1 percent of the herb in alcohol. Dose, 
10 to 45 minims. 
MENTHA VIRIDIS (Spearmint).-The dried 
leaves and flowering tops of M. spicata, the " mint" 
of the kitchen garden. Its constituents and prop- 
erties are identical with those of peppermint, but 
its odor and taste differ therefrom. Spearmint 
corresponds in action to peppermint, but is less 
powerful. It is employed to correct flatulence 
and to relieve colic, and makes an agreeable flavor- 
ing for mixtures.. 
Oleum M. V. is the volatile oil distilled from the 
plant. Dose, 2 to 5 minims. Aqua M. V. has 2 
parts of the oil in 1000 of distilled water. Dose, 2 to 6 
drams. Spiritus M.V., essence of spearmint, is an al- 
coholic solution containing 10 percent of the oil and 1 
percent of the bruised herb. Dose, 10 to 45 minims. 
MENTHOL.-C10H19OH. A secondary alcohol, 
obtained from oil of peppermint, from which it 
separates in crystalline form on cooling. Slightly 
soluble in water, freely so in alcohol, ether or 
chloroform. Dose, 1/2 to 3 grains, in a pill or 
spirituous sqlution several times a day. 
Therapeutics.-Menthol is highly praised as an 
external application in various neuralgias, sciatica, MERCUROL 
pleurodynia, and toothache. For neuralgia it is 
used in saturated alcoholic solution painted over 
the affected nerve. For toothache a crystal in- 
troduced into the carious cavity is promptly ano- 
dyne. In spray containing 5 to 20 percent it is 
highly efficient in epidemic influenza and in tuber- 
culous laryngitis. It is a good application in para- 
sitic skin diseases, and has marked value as an an- 
tipruritic. Its vapor by inhalation is efficient 
against cough, and it has considerable power as an 
anti-emetic, having stopped nausea and vomiting 
after the usual remedies had failed. For this 
purpose ten drops of a 20 percent solution in olive 
oil are given on sugar. 
The drug has been used in the vomiting of preg- 
nancy, in hourly doses of a teaspoonful of the fol- 
lowing: 
1$. Menthol, gr. xv 
Whisky, ' 3 vj 
Syrup, 3 j. 
It is also used as a carminative and in gastralgia, 
in the dose of 1 to 2 grains 3 times daily in pill or 
solution. 
MERCUROL.-A compound of mercury with 
yeast nuclein. It contains about 10 percent of 
mercury. It is used extensively as an injection in 
1 percent solution, in gonorrhea and cystitis. 
Dose, 1/2 to 3 grains, three times a day. 
MERCURY (Hydrargyrum; Quicksilver).-Hg = 
200; quantivalence 11, iv. The only liquid metal- 
lic element, hence the common name, quicksilver. 
In medicine the metal, its nitrate, oxids, chlorids, 
and iodids are the salts most commonly, the sul- 
phid less frequently, used. 
Therapeutics.-In small doses, continued not too 
long a time, it is a tonic, purgative, and alterative. 
In larger doses, or too long continued, it is likely 
to produce a condition called hydrargyrism, saliva- 
tion, or ptyalism. In "biliousness" mercurial 
purgatives have long been a favorite remedy, blue 
mass and mercurous chlorid or calomel being 
usually employed. In syphilis mercuric chlorid 
and mercuric iodid are generally considered spe- 
cific. Mercury in the form of calomel is useful in 
glandular inflammations, and locally in corneal 
inflammations. Formerly calomel was much used 
in typhoid fever and malarial fevers. The soluble 
salts of mercury are highly poisonous. 
The metal itself is inert, but by combination with 
the acids and fluids of the body becomes active, and 
is easily absorbed in any form. In the blood its 
effects, in small doses, are tonic, but in quantity 
it indirectly produces impoverishment thereof. 
From the blood it enters the tissues, where it re- 
mains for an indefinite period, exerting a peculiar 
influence, termed alterative, on all processes 
characterized by growth of young cells. It stimu- 
lates most of the glands of the body to the pro- 
duction of pathologic secretions, especially the 
salivary glands and the pancreas. It tends to 
accumulate in the liver, stimulating the flow of 
bile. Its excretion is hastend and completed by 
the use of potassium iodid. In small doses ad- 
ministered for a short time the mercurial prepara- 
tions are blood-tonics. 
MERCURY 
A purgative and cholagog pill: 
1$. Extract of colocynth, 3 ss 
Powdered scammony, gr. xx 
Calomel, » gr. xij. 
Make into 12 pills; take 1 at night, as neces- 
sary. 
In chorioretinitis: 
1$. Mercuric chlorid, gr. iij 
Extract of belladonna, gr..vj. 
Make 60 pills; give 1 pill after each meal. 
In eczema (calomel ointment): 
I). Calomel, 
Magnesium car- 
bonate, 
each, gr. xl 
Cold cream, 3 j. 
Use in eczema. 
In dropsy of chronic heart- and liver-disease: 
1$. Mass of mercury, 
Powdered squill, 
Powdered digi- 
talis, 
each, gr. xx. 
Mix and make into 20 pills; give 1 pill 
thrice daily. 
In late syphilis: 
1$. Mercuric chlorid, gr. j to jss 
Potassium iodid, 3 jss to iv 
Compound syrup of sar- 
saparilla, 3 j 
Water, enough to make 3 ij • 
Give 1 teaspoonful 3 times daily. 
In syphilis: 
1$. Mercury biniodid, gr. j 
Potassium iodid, 5 ij 
Peppermint water, q. s. 3 iij. 
Give 1 teaspoonful after each meal. 
In late syphilis, for hypodermic use: 
3. Mercuric chlorid, gr. vj 
Sodium chlorid, gr. xxxvj 
Distilled water, 5 iijss. 
Inject 5 to 8 drops daily, hypodermically. 
In constipation: 
I). Mercuric chlorid, 
Strychnin sul- 
phate, 
each, gr. ss 
Quinin sulphate, gr. xij 
Extract of belladonna, gr. ij. 
Mix and make into 12 pills; take 1 night and 
morning. 
Yellow wash: 
1$. Bichlorid of mercury, gr. xv 
Lime-water, O ij. 
Mix and make into a lotion; apply to 
syphilitic sores. 
Poisoning.-The first symptoms of salivation are 
fetid breath, swollen and spongy gums, having a 
bluish line along their margins, stomatitis, sore and 
loosened teeth, inflamed and tender salivary 
glands pouring out a peculiar, thin saliva of foul 
odor in large quantity, and a metallic taste in the 
mouth. Emaciation, pallor, edema, ulcerated MERCURY 
MESENTERIC CYSTS 
skin, erythematous, vesicular, or pustular erup- 
tions, headache, insomnia, neuralgia, tremor 
through paresis of the muscles of the head and 
extremities, epilepsy, coma, and convulsions may 
ensue. An influenzal condition is not uncommon. 
Salivation is most readily produced by blue mass, 
next by calomel, and less easily by gray powder. 
Children are not easily salivated. Inhalation of 
mercurial vapors is likely to affect the nervous 
system most; its internal administration and that 
by inunction are more likely to produce salivation. 
Treatment consists in the withdrawal of the mer- 
cury, antiseptic mouth-washes, particularly the 
potassium chlorate, and, later, the use of the iodids 
as eliminatives. 
Poisoning by the bichlorid requires the prompt 
oral administration of large amounts of albumin, 
the whites of eggs being most easily obtained. 
The stomach should be washed out, external heat 
applied about the body, and stimulants to the 
respiration and circulation given. If death does 
not ensue at once, the organic changes in the gastro- 
intestinal tract, such as strictures, sloughs, and 
destruction of the peptic glands and ulceration, 
generally cause a protracted convalescence, or 
may eventually result in a fatal issue. 
Preparations.-H. Ammoniatum, ammoniated 
mercury, "white precipitate," mercuric ammonium 
chlorid, NH2HgCl, is used externally. H. Am- 
moniati, Ung., "white precipitate ointment"- 
ammoniated mercury 10, white petrolatum 50, 
hydrous wool fat 40. H. Chloridum Corrosivum, 
HgCl2 (H. Perchloridum, B. P.), corrosive chlorid 
of mercury, mercuric chlorid, "bichlorid of mer- 
cury," "corrosive sublimate." Soluble in water 
and alcohol; antisyphilitic. Dose, 1/80 to 1/10 
grain. Very poisonous. H. Chloridum Mite, 
Hg2Cl2 (H. Subchloridum, B. P.), mild chlorid or 
subchlorid of mercury, mercurous chlorid, "calo- 
mel"-laxative, tonic, and antipyretic. Insolu- 
ble in water and alcohol. Dose, 1/20 to 5 grains. 
H. cum Creta, mercury with chalk, "chalk-mix- 
ture," "gray powder," contains mercury 38, 
clarified honey 10, prepared chalk 57, water 
sufficient quantity. Dose, 1/2 to 10 grains. H., 
Emplastrum, mercurial plaster-mercury 30, 
oleate of mercury 1, hydrous wool fat 10, lead 
plaster 59. H., Arsenii et lod., Liq., Donovan's 
solution. See Arsenic. H. Flav., Lotio, unof., 
"yellow wash" for syphilitic sores-corrosive 
sublimate 18 grains, lime-water 10 ounces. H. 
lodid. Flavum, Hgl, yellow iodid of mercury, 
mercurous iodid, protiodid. Dose 1/10 to 1/3 
grain. H. Iodid. Rubrum, Hgl2, red iodid or bin- 
iodid of mercury, mercuric iodid. Soluble in a 
solution of potassium iodid. Poisonous. Dose, 
1/50 to 1/10 grain. H., Massa, "blue mass," 
"blue pill," has mercury 33, licorice 10, althaea 15, 
glycerin 9, honey of rose 33. It is used mainly 
as a purgative. Dose, 1/2 to 10 grains. H. 
Nigra, Lotio, unof., "black wash" for syphilitic 
sores-calomel 30 grains, lime-water 10 ounces. 
H. Nitrat., Liq., solution (60 percent) of mercuric 
nitrate. It is used as an escharotic. H. Nitrat., 
Ung., citrine ointment-mercury 7, nitric acid 17, 
lard oil 76. H., Oleat., contains yellow oxid 25, dis- 
tilled water 25, oleic acid to 100. H. Oxid. Flav., 
yellow oxid of mercury.. Insoluble in water; solu- 
ble in nitric and hydrochloric acids. It is used in 
the preparation of ointments, etc. H. Oxid. Flav., 
Ung., contains 10 percent of the oxid. H. Oxid. 
Rub., red oxid of mercury. Dose, 1/50 to 1/10 of 
a grain. H. Oxid. Rub., Ung., contains 10 percent 
of the oxid. H. Oxycyanid. It is said to be less 
irritating than mercuric chlorid. It has greater 
antiseptic power than the latter, it is said; and it 
does not corrode steel instruments. Dose, hypo- 
dermically, is the same as the chlorid; it is used 
locally in 1:5000 solution. H. Subsulph. Flav., 
yellow subsulphate of mercury, basic mercuric 
sulphate, "turpeth mineral." Soluble in nitro- 
hydrochloric acid. Dose, for emesis, 2 to 5 
grains. H., Unguent., mercurial ointment-mer- 
cury 50, lard 25, suet 23 oleate of mercury 2. 
These are triturated until the globules of mercury 
disappear under a magnifying glass. It is used to 
produce the physiologic effects of mercury by in- 
unction. H. Ung., Dil., Blue ointment has of the 
preceding 67, and petrolatum 33, well mixed. Gray 
Oil, Oleum cinereum, a semifluid, fatty, mercurial 
liquid introduced into medicine by Lang, of Vienna, 
in 1886. It is used in the treatment of syphilis 
by injections. It is prepared as follows: A given 
quantity of lanolin-1 or 2 drams-is rubbed up 
with sufficient chloroform to emulsify it. This 
mixture is to be thoroughly triturated, during 
which operation the chloroform will evaporate. 
While the mixture is still in a fluid state metallic 
mercury to the amount of double the quantity of 
the lanolin is to be added, the trituration being 
meanwhile continued. As a result, a pomade of 
mercury is left, which represents 2 parts of mer- 
cury and 1 part of lanolin. This is called strong 
gray lanolin ointment. From this salve-basis a 50 
percent oleum cinereum, or gray oil, may be ob- 
tained by mixing 3 parts with 1 part of olive oil. 
A mild gray lanolin ointment may be made in the 
same manner as the strong, by taking equal parts 
of lanolin and mercury and thoroughly mixing 
them. From this salve-basis a 30 percent gray oil 
may be made by mixing 6 parts with 4 parts of 
fresh almond oil or olive oil. 
MERYCISM.-See Rumination. 
MESENTERIC CYSTS.-The chief tumors of 
the mesentery are cysts of congenital origin, a 
sequestration from the intestinal canal (vitellind 
duct), the pronephros (Mullerian duct) or meso- 
nephros (Wolffian duct) showing an epithelial 
lining or not, and a wall of muscular or fibrous 
tissue or both. An hydatid or dermoid cyst and a 
teratoma or included fetus may also occur, and 
sometimes an ovarian cyst may become detached 
from its pedicle and grafted on to the mesentery. 
Formerly these cysts were held to be chyle cysts 
from obstruction of the lacteals, or degeneration in 
the lymphatic glands. Now such chyle cysts, if 
they occur, are considered quite the exception. 
The typical cyst should contain fluid with epithelial 
debris. Blood or chyle may gain entrance second- 
arily by estravasation. The special signs are a 
movable tumor covered by resonant intestine. At 
times there are symptoms of abdominal obstruction. MESENTERIC GLANDS 
METRIC SYSTEM 
Treatment.-The cyst should be carefully shelled 
out after pushing aside the mesenteric vessels; only 
when absolutely necessary should the cyst-wall be 
sutured to the abdominal wound and drained. If 
the mesenteric vessels are involved the portion of 
intestine supplied has also to be excised to avoid 
gangrene (Spencer and Gask). 
MESENTERIC GLANDS.-See Tabes Mesen- 
TERICA. 
MESMERISM.-See Hypnotism. 
MESOTAN.-Ericin. The methyl-oxymethyl- 
ester of salicylic acid. A yellow fluid, containing 
71 percent of salicylic acid, is readily absorbed by 
the skin, and, mixed with an equal quantity of 
olive oil, is used with friction as an external remedy 
in rheumatism. 
METATARSALGIA (Morton's Disease).-It is 
characterized by severe neuralgic pain beginning 
at the side of the distal end of the third or fourth 
metatarsal bone and extending up into the foot 
and leg. It is the result of tight shoes. Treat- 
ment consists in wearing a flat-foot brace if neces- 
sary and properly fitting shoes, or, in extreme cases 
in resection of the head of the bone or excision of the 
superficial branch of the external plantar nerve. 
METEORISM.-See Tympanites. 
METHYL.-In chemistry a radical molecule of 
the composition of CH3. It is the base of a large 
number of compounds, including alcohol, methyl 
spirit, and several ptomains. 
Methyl acetanilid. See Exalgin. 
Methyl chlorid is a colorless gas with an odor 
resembling ether or chloroform, and used to pro- 
duce local anesthesia. It is applied to the skin 
in a spray or by means of a cotton tampon. 
The spray should not continue longer than from 
2 to 4 minutes. Its advantages over an ether 
spray are its noninflammability and its more rapid 
effect. Methyl chlorid is employed in minor 
surgical cases, such as opening boils and re- 
moving small growths, in pruritus, in neuralgias, 
and to allay spinal irritation. 
Methyl salicylate is the active principle of winter- 
green, of which the oil contains about 90 percent. 
It has the same properties as the oil of gaultheria, 
and may be used for the same purposes. It is also 
used to disguise the taste of unpalatable drugs, 
and as a substitute for the salicylates in rheuma- 
tism. It is valuable as an external application in 
arthralgias. A liniment is prepared as follows: 
» 
employed in diphtheria and forms of infectious 
laryngitis. In circumscribed sarcoma and car- 
cinoma deep injections of methyl-violet have been 
used. 
METHYLENE.-CH2. A bivalent hydrocarbon 
radicle occurring in many compounds. 
Methylene-blue, methylthionin hydrochlorid, 
is a coal-tar dye prepared from dimethyl anilin; 
it is much used in the arts and as a stain 
in bacteriology. Its 10 percent solution is 
recommended as a local application in diphtheria, 
tonsillitis, scarlatinal sore throat, and other in- 
flammatory conditions, and internally adminis- 
tered it has proved serviceable as an antiperiodic 
and antalgesic. Dose, 1 to 6 grains in capsule; 2 
grains of powdered nutmeg should be given with 
each dose, to prevent strangury. 
Methylene bichlorid, CH2C12, is a general anes- 
thetic. It is asserted by Genther and Eichholz 
to be more susceptible of management than chloro- 
form in protracted operations. Much of the 
methylene bichlorid contains 50 to 75 percent of 
chloroform. Unof. 
METRIC SYSTEM.-A decimal system of weights 
and measures employed in France, Germany, and 
other countries, and used generally in the sciences. 
The standard is the meter, the 1/10,000,000 part of 
a quadrant of a meridian circle of the earth. The 
standard of capacity is the liter, a cubic volume 
1/10 of a meter in each dimension. The standard 
of weight is the gram, the weight of 1/1000 of a liter 
(1 cubic centimeter) of distilled water at its maxi- 
mum density. The unit of superficial measure is 
the are, a square whose side is 10 meters, or a deca- 
meter. As the unit of microscopic measurement, 
the thousandth part of a millimeter has been 
adopted. It is called micron or microm, micro- 
millimeter; represented by the sign g. The multi- 
ples are expressed by the prefixes deca, hecto, 
and kilo; the subdivisions by the prefixes deci, 
centi, and milli. 
1000 meters =1 kilometer. 
100 meters =1 hectometer. 
10 meters =1 decameter. 
.1 meter =1 decimeter. 
.01 meter =1 centimeter. 
.001 meter =1 millimeter. 
1000 liters =1 kiloliter. 
100 liters =1 hectoliter. 
10 liters =1 decaliter. 
.1 liter =1 deciliter. 
.01 liter =1 centiliter. 
.001 liter =1 milliliter. 
1000 grams =1 kilogram. 
100 grams =1 hectogram. 
10 grams =1 decagram. 
.1 gram =1 decigram. 
.01 gram =1 centigram. 
.001 gram =1 milligram. 
3. Ether, 
Alcohol, 
Methyl salicylate, 
each, 3 j 
Soap liniment, enough for O j. 
Use as a liniment. 
Methyl-violet, or pyoktanin, is an anilin dye 
appearing in the form of a blue, odorless powder, 
soluble in 75 parts of water. It is a moderately 
efficient antiseptic, and is not coagulated by albu- 
min, and stains the tissues blue. In solutions of 
1:2000 or 1:1000 it has been used in ulcerative 
keratitis, purulent ophthalmia, and in iritis. The 
same strength solutions have been used in empy- 
ema to flush out the pleural sac, and it has'been 
In common practice, however, the following 
divisions only are used, the others being expressed 
in figures: 
10 millimeters =1 centimeter. 
100 centimeters =1 meter. 
1000 meters =1 kilometer. 
1000 cubic centimeters =1 liter. 
1000 milligrams =1 gram. 
1000 grams =1 kilogram METRITIS 
MICROSCOPE 
The following are the equivalent values: 
mezereinic acid. Mezereum is an ingredient of the 
compound fluidextract of sarsaparilla. Dose, 1 to 
10 grains. Fluidextractum mezerei, is too acrid 
for internal use. Mezereum is a sialogogue, and 
an intensely acrid, irritant poison, producing 
violent vomiting, purging, nephritis and gastro- 
enteritis. In small doses it is laxative and diuretic, 
and has had considerable reputation as an altera- 
tive. Externally the recent bark is a powerful 
local irritant, speedily producing vesication. 
Mezereum is rarely used internally by itself, but is 
employed in mixtures with sarsaparilla, etc., as an 
alterative in syphilis, rheumatism and some skin 
diseases of chronic type, but with doubtful efficacy. 
It has been used with good effect in toothache and 
as a masticatory in paralysis of the tongue. Its 
principal use is as a local irritant to keep up the 
discharge from issues or blisters, and to stimulate 
indolent ulcers. 
MICROCEPHALUS.-A condition in which a 
child is born with the skull completely ossified, or 
one in which ossification has taken place soon 
after birth. 
The operation for the relief of microcephalus is 
known as linear craniotomy; it is performed by 
making a longitudinal incision through the skin to 
one side of the sagittal suture, from the occipital 
bone to the hair line in front, and a transverse 
incision from the hair line downward. The 
flap is to be reflected back and a small opening 
made in the skull by means of a trephine; then, 
with Rongeur forceps, a groove is cut as far for- 
ward as the angle of the wound in front; from this 
point a lateral groove is made. The parts are then 
irrigated, all hemorrhage controlled, and the flaps 
brought together by means of interrupted silk- 
worm-gut sutures. In from 6 to 12 months a 
similar operation should be performed on the other 
side of the sagittal suture. 
MICROPHOTOGRAPHY.-The production of 
photographs of microscopic size, usually of large 
objects. These photographs must then be exam- 
ined with a magnifier or microscope. In French 
and German this term is also employed for Pho- 
tomicrography (g. v.). 
MICROSCOPE.-An optical apparatus for giv- 
ing an enlarged and distinct image of a minute and 
near object. There are usually 2 or more lenses 
or lens-systems, of which one, the objective, 
placed near the object, gives an enlarged and 
inverted real image. The other, the ocular, acting 
like a simple microscope, gives an enlarged virtual 
image of the real image. 
The microscope is the most important labora- 
tory instrument, and should be, so far as means 
will permit, the best that skill can produce. 
American microscopes are now as well made as 
those of foreign firms. The medium form of stand 
is of preference. The large stand is too heavy and 
too high. The necessary objectives are a low, a 
high, and a 1/12 oil-immersion. Two eye-pieces, 
a low and a high, will be found sufficient for ordi- 
nary purposes. The oil-immersion lens should 
always be cleaned after using by wiping off the oil 
with an old linen or silk handkerchief or with fine 
tissue-paper. If the lens is sticky, moisten the 
1 meter =39.37 inches. 
1 liter =1 quart i gill, U. S 
measure. 
1 gram = 15.43 grains. 
1 minim = 0.061 cubic centi- 
meter. 
See also Weights and Measures. 
The following metric conversion table has been 
compiled by Mr. C. W. Hunt, of New York: 
Millimeters multiplied by . 03937 equals inches. 
Millimeters divided by 25.4 equals inches. 
Centimeters multiplied by . 3937 equals inches. 
Centimeters divided by 2.54 equals inches. 
Meters equals 39.37 inches. (Acts of Congress.) 
Meters multiplied by 3.281 equals feet. 
Meters multiplied by 1.094 equals yards. 
Kilometers multiplied by . 621 equals miles. 
Kilometers divided by 1.0093 equals miles. 
Kilometers multiplied by 3280.7 equals feet. 
Square millimeters multiplied by 0.155 equals square inches. 
Square millimeters divided by 645.1 equals square inches. 
Square centimeters multiplied by .155 equals square inches. 
Square centimeters divided by 6.451 equals square inches. 
Square meters multiplied by 10.764 equals square feet. 
Square kilometers multiplied by 247.1 equals acres. 
Hectares multiplied by 2.471 equals acres. 
Cubic centimeters divided by 16.383 equals cubic inches. 
Cubic centimeters divided by 3.69 equals fluidrams 
(U. S. P.). 
Cubic centimeters divided by 29.57 equals fluidounces 
(U. S. P.). 
Cubic meters multiplied by 35.315 equals cubic feet. 
Cubic meters multiplied by 1.308 equals cubic yards. 
Cubic meters multiplied by 264.2 equals gallons (231 cubic 
inches). 
Liters multiplied by 62.022 equals cubic inches. (Act of 
Congress.) 
Liters multiplied by 33.84 equals fluidounces (U. S. P.). 
Liters multiplied by . 2642 equals gallons (231 cubic inches). 
Liters divided by 28.316 equals cubic feet. 
Hectoliters multiplied by 3.531 equals cubic feet. 
Hectoliters multiplied by 2.84 equals bushels (2150.42 cubic 
inches). 
Hectoliters multiplied by . 131 equals cubic yards. 
Hectoliters divided by 20.42 equals gallons (231 cubic inches) 
Grams multiplied by 15.432 equals grains. (Act of Congress.) 
Grams multiplied by 981 equals dynes. 
Grams (water) divided by 29.57 equals fluidounces. 
Grams divided by 28.35 equals ounces avoirdupois. 
Grams per cubic centimeter divided by 27.7 equals pounds 
per cubic inch. 
Joule multiplied by .7373 equals foot-pounds. 
Kilograms multiplied by 2.2046 equals pounds. 
Kilograms multiplied by 35.3 equals ounces avoirdupois. 
Kilograms divided by 1102.3 equals tons (2000 pounds). 
Kilograms per square centimeter multiplied by 14.223 equals 
pounds per square inch. 
Kilogrammeters multiplied by 7.233 equals foot-pounds. 
Kilograms per meter multiplied by .672 equals pounds per 
square foot. 
Kilograms per cubic meter multiplied by 0.26 equals pounds 
per cubic foot. 
Kilograms per cheval vapeur multiplied by 2.235 equals 
pounds per horse-power. 
Kilowatts multiplied by 1.34 equals horse-power. 
Watts divided by 746 equals horse-power. 
Watts divided by .7373 equals foot-pounds per second. 
Calory multiplied by 3.968 equals B. T. U. 
Cheval vapeur multiplied by . 9863 equals horse-power. 
Centigrade multiplied by 1.8 + 32, equals degrees Fahrenheit. 
Francs multiplied by . 193 equals dollars. 
METRITIS.-See Uterus (Inflammation). 
METRORRHAGIA.-See Menorrhagia. 
ME Z EREUM (Mezereon).-The bark of Daphne 
Mezereum, containing an inert, fixed oil, an in- 
active glucosid, daphnin, and an acrid resin, 
which is the anhydrid of a resinous acid named MICROSCOPE 
MICTROTOME 
cloth with water or, where the oil has dried, with 
benzol or xylol. The same process may be used 
for the dry lenses, but it must be done quickly, 
so as not to soften the balsam in which the lenses 
are embedded. Ordinarily, a dry cloth is suffi- 
cient. The concave mirror is to be used only when 
some near object, such as wall objects, is reflected 
into the field of vision or when artificial light is 
employed. A Welsbach burner, or, better, the 
incandescent electric light with ground-glass globe, 
furnishes the best illumination. A piece of blue 
glass inserted over the mirror or just below the 
object to be examined will correct the slightly 
yellowish tint of these lights. 
morbid discharges, cyst contents, cerebrospinal 
fluid, new growths, parasites, and to examinations 
of food-stuffs, drugs, and in medicolegal inquiries. 
Besides the microscope, the use of additional 
apparatus is required for the examination of tis- 
Mechanical Stage 
uses, microorganisms, and their secretionsand 
products. As most secretions and discharges of 
the body are of a fluid nature, they do not require 
the addition of any medium; but if necessary, 
a 0.75 percent solution of sodium chlorid, or a 
3 percent solution of glycerin in distilled water, 
having a few crystals or carbolic acid added to 
prevent the growth of fungi, will suffice. The 
preparation of speci- 
mens for microscopic 
examination is de- 
scribed under Patho- 
logic Technic (7. v.). 
MICROSTOMA.- 
Any lessening of the 
size of the mouth, even 
to complete i mperf ora- 
tion of the lips. It is 
either congenital or 
traumatic, arising 
from burns or syphi- 
litic ulcers, etc. It is 
very rarely seen, ex- 
cept as the result of an 
accident. If there is 
complete imperf ora- 
tion, or if the mouth 
is so small that the 
child is unable to hold 
the nipple by the lips, 
a plastic operation 
must be immediately 
performed. 
MICROTOME.-An instrument for making thin 
sections for microscopical examination. The 
microtomes of Schanze, Rutherford, Hamilton, 
Williams, Lewis, Jung, Leiter, Ryder, Minot, 
Bardeen, Ranvier, and Cathcart are the most used. 
A freezing microtome is one in which the tissue 
is frozen, in order to secure the hardness required 
for properly cutting sections. It operates by the 
rapid evaporation of ether or rhigolene through the 
medium of a special apparatus, after which the 
E. Eyepiece; D. Draw tube;- T. Body tube; RN. Revolving 
nosepiece; O. Objective; PH. Pinion head; MH. Micrometer 
head; HA. Handle arm; >S. Stage; SS. Substage; M. Mirror; 
B. Base; R. Rack; P. Pillar; I. Inclination joint. 
Microscope 
It must be recognized that the microscope is 
but an aid to one of our senses. It merely ex- 
tends our power of observation. The formation 
of a diagnosis-the first aim of practical medicine 
-is the result of judgment founded upon observa- 
tion, and the microscope permits wider application 
of the sense of sight. 
With a mechanical stage the microscopist can 
examine systematically and conveniently an entire 
slide area. By means of the graduated scale 
readings, he also can locate a particular point on 
the field and return to it at any time by simply 
attaching his stage in the same position and set- 
ting his adjustments to accord with his original 
readings. 
The clinical uses of the microscope extend to 
the investigation of the various discharges and 
secretions of the body, such as the urine, gastric 
contents, vomitus, feces, sputum, blood, milk, 
Hand Microtome MICTURITION 
MILITARY SURGERY 
specimen is cut by means of the blade of a carpen- 
ter's plane. CO2 liquid gas, also used, offers the 
most rapid and convenient method for freezing 
specimens for sectioning. 
Celloidin Microtome.-Of this variety there are 
2 types-one in which the section is raised by a 
screw, the other in which the object is raised by 
being moved up an inclined plane. (The first 
variety is preferred by Mallory and Wright.) 
By means of a sharp blade having the shape of a 
razor, placed at an angle, the specimen is easily 
cut after being hardened in celloidin. 
Paraffin Microtome.-Frequently paraffin sec- 
tions may be cut in a celloidin microtome, but one 
made specially for this work is preferable. That 
devised by Minot is advised. 
MICTURITION.-See Urethra, Urinary 
Stream, Urine (Retention, Suppression). 
MIGRAINE.-A unilateral paroxysmal pain in 
the head, periodic, accompanied by nausea, often 
vomiting, intolerance of light and sound, and 
incapability of mental exertion, the brain being 
temporarily prostrated and disturbed. 
Synonyms.-Megrim; hemicrania; sick head- 
ache; bilious headache; blind headache. 
Causes.-In the majority of patients the nervous 
predisposition to migraine is inherited, but whether 
inherited or acquired, it commonly develops before 
the age of 30. 
Among the many exciting causes are eye-strain, 
disturbances of digestion, irritation of the ovaries 
or uterus, worry, exacting mental labor, sexual 
excesses, and insufficient sleep. The causes of 
many attacks, however, are wrapped in mystery. 
Symptoms.-Attacks of migraine occur in irregu- 
lar paroxysms, the intervals between being free 
from pain or nervous disturbance. For a day or 
two preceding the paroxysm it will be ascertained, 
on close questioning, that there were a feeling of 
fatigue without apparent cause, heaviness over 
the eyes, with some flatulency and indigestion. 
The attack proper is ushered in by chilliness, 
nausea, often vomiting, yawning, and general 
muscular soreness, with intolerance of light, and 
noises in the ears and incapability for mental exer- 
tion, and pain of a sharp, shooting character, of 
great intensity and persistency, localized most 
frequently in the frontal, temporal, or occipital 
regions of the left side; at the same time there is 
tenderness over the whole side of the head. Rarely, 
the pain is felt on the right side, and still more 
rarely on both sides at the same time. The nausea 
and other digestive symptoms may follow the 
onset of the pain instead of preceding it. There is 
more or less disturbance of the circulation, tem- 
perature, and secretions of the affected parts. At 
times there is a marked contraction of the vessels, 
when the face is pale, the eyes shrunken, and the 
pupils dilated; again, the vessels may be dilated, 
when the face is flushed, the conjunctivae in- 
jected, and the pupils contracted. Motion, sound, 
and light aggravate the acute suffering. 
The attack may continue with more or less 
intensity from a few hours to 2 or 3 days, the 
average duration being 24 hours. 
Diagnosis.-The symptoms are so characteristic 
that an error seems impossible. It may, however, 
be confounded with anemic headache, hyperemic 
headache, dyspeptic or bilious headache, and 
neuralgic or rheumatic headache. The pains of 
organic brain disease must be excluded. 
Prognosis is favorable. The affection is free 
from danger to life. In a fair number of cases the 
susceptibility to attacks declines as the person 
advances in years, it being rarely seen after 50 
years. 
Treatment must be directed to the cause. Any 
eye-strain, digestive trouble, or uterine disease 
must be corrected. To abort an attack of mi- 
graine or dispel a paroxysm after its onset, any one 
or two of 4 remedies are almost infallible. One is 
a hypodermic injection of morphin sulphate, 1/4 
grain, with atropin sulphate, 1/120 grain, or anti- 
pyrin, 20 grains, repeated in an hour or two; or 
phenacetin, 10 grains, repeated in an hour or two. 
In many attacks fluidextract of cannabis indica, 2 
or 3 drops every half hour or hour for a number of 
doses, is curative. The local use of menthol 
pencils eases the pain. 
The following may be given: 
T|. Acetanilid, gr. xx 
Codein sulphate, 
Monobromated camphor, 
each, gr. v. 
Make 10 pills. Take 1 pill every 2 hours 
until relieved. 
In the intervals between the paroxysms meas- 
ures to improve the general system should be used, 
and to overcome as far as possible any of the 
etiologic factors in its production. For this pur- 
pose extract of cannabis indica, 1/4 grain 3 times 
daily for several months, is highly recommended. 
See Headache. 
MILIARIA (Prickly Heat).-See Sweat Glands; 
Urticaria. 
MILIARY FEVER (Sweating Sickness).-A 
rare infectious fever, occurring in epidemics in 
limited districts in Europe, characterized by 
miliaria, fever, and profuse sweating. Treatment 
is expectant and symptomatic. 
MILITARY SURGERY.--Military surgery differs 
little from ordinary emergency surgery. The 
surgeon in daily practice has learned long ago that 
every accidental wound must practically be 
regarded and treated as an infected wound. In 
this respect the military surgeon of to-day has the 
advantage over his colleague in civil practice in 
knowing that the small-caliber bullet inflicts 
wounds which per se are more often aseptic than 
septic. Senn's experience in Cuba showed that 
the small jacketed bullet seldom carries with it 
into the tissues clothing or any other infectious 
substances. Most of the wounds of the soft 
tissues, uncomplicated by visceral lesions, which 
in themselves would become a source of in- 
fection, healed by primary intention in a re- 
markably short time. If infection followed, it 
usually did so in the superficial portion of the 
wound in connection with the skin, and, what is 
more than suggestive, the wound of exit was more 
frequently affected than the wound of entrance. 
This can be readily explained from the larger size MILIUM 
MILK 
of the wound and more extensive laceration and 
tearing of the tissues. In many of the cases ideal 
healing of the wound did not occur, owing to a 
subsequent limited superficial suppuration. The 
deep tissues were seldom implicated. 
The many failures in protecting the more serious 
wounds against infection are attributable to 3 
principal causes: (1) Inadequate supply of first 
dressing; (2) faulty application of first dressing; 
(3) unnecessary change of dressing. In all cases 
in which the first examination does not reveal the 
existence of complications which require subse- 
quent operative treatment the diagnosis tag should 
convey this important instruction: "Dressing not 
to be touched unless symptoms demand it." Such 
instruction is significant, and must be followed to 
the letter by all surgeons in subsequent charge of 
the patient. 
For years Senn used as an antiseptic powder a 
combination of boric acid and salicylic acid, 4:1, 
with the most satisfactory results. He was also 
partial to sterile absorbent cotton for this particu- 
lar purpose, as it constitutes a more perfect filter 
than loose gauze. A teaspoonful of this powder 
dusted on the wound forms, with the blood that 
escapes and the overlying cotton, a firm crust, 
which seals the wound hermetically. Should the 
primary dressing become saturated with blood, 
the same powder should be dusted over the wet 
dressing, and an additional compress of cotton is 
added to the dressing. After the first dressing has 
been applied it should not be removed except for 
good and convincing reasons. Much can be done 
in the after-treatment in the way of adjusting the 
bandage and immobilizing the injured part, but 
the first dressing must remain unless local or 
general symptoms set in which would warrant its 
removal. Malaria and yellow fever, in the tropics, 
are responsible for many unnecessary changes of 
dressing. The appearance of fever in a wounded 
man naturally leads to the suspicion that there is 
something wrong in the wound. Many dressings 
were changed on this ground; nothing abnormal 
was found in the wounds, and a day or two later 
the nature of the fever was recognized, and the 
patients were either given quinin or were sent to 
the yellow-fever hospital, in accordance with the 
diagnosis made. Every change of dressing, more 
especially in military practice, is attended by risk 
of infection, and must be scrupulously avoided, 
unless local or general symptoms indicate the 
existence of complications which demand surgical 
intervention. See Gunshot Wounds, Roentgen 
Rays. 
MILIUM (Grutum).-A skin-disease character- 
ized by the formation of small, roundish, whitish, 
sebaceous, noninflammatory elevations situated 
just beneath the epidermis. They are found 
mainly on the face, eyelids and forehead of elderly 
persons, and may exist in immense numbers. 
They may undergo calcification, giving rise to 
cutaneous calculi. 
Colloid milium is a rare skin disease,characterized 
by the presence, especially on the bridge of the nose, 
forehead, and cheeks, of minute, shining, flat, 
or slightly raised lesions of a pale lemon or bright 
lemon color. It is a form of colloid degeneration 
of the skin affecting persons of middle or advanced 
age. 
MILK.-The secretion of the mammary glands 
of mammalia, consisting of water, casein, albumin, 
fat, milk-sugar, and salts. Cream consists mainly 
of the fats that rise to the surface of the milk. Skim- 
milk is the residue left after the removal of the 
cream. Buttermilk is cream from which the fatty 
matter has been removed. It should contain not 
less than 10 percent of cream. The reaction of 
milk, when first secreted, is alkaline, but it becomes 
acid on standing, as a result of fermentative 
processses. 
The following table (from Bartley) shows the 
chief differences between human and cow's milk: 
Properties. 
Human Milk. 
Cow's Milk. 
Physical ap- 
pearance. 
Bluish, translucent, 
odorless, sweetish. 
Opaque, white or yel- 
lowish-white, distinct 
odor, feebly sweet 
taste. 
Specific 
gravity. 
1026 to 1036 
1029 to 1035. 
Reaction.... 
Amphoteric or slightly 
alkaline. 
Amphoteric or slightly 
acid; becomes quick- 
ly acid on exposure 
to air. 
Behavior on 
boiling. 
Does not coagulate, 
and forms a very 
slight pellicle, scarce- 
ly observable. 
Does not coagulate, 
but forms a distinct 
pellicle of casein and 
lime-salts. 
Spontaneous 
coagulation. 
Coagulates only after 
one to two days, at 
room temperature. 
Coagulates after six to 
twelve hours at room 
temperature; due to 
lactic acid. 
Coagulation 
with rennet. 
Coagulates incomplete- 
ly in small, isolated 
flocculi, never form- 
ing visible curds. 
Coagulates at body 
temperature, sepa- 
rating into curdy 
masses and opales- 
cent whey. 
Fat 
Butter yellowish, simi- 
lar to cow-butter; 
sp. gr. at 15° C. = 
0.966; melts at 
34° C. 
Butter yellow-white; 
sp. gr. at 15° C. = 
0.949 to 0.996; melts 
at 35.8° C. 
Composition 
of fat. 
Olein, palmitin, stear- 
in, butyrin, caprin, 
caproin, myristin 
Olein, palmitin, stear- 
in, caproin, caprylin, 
caprin, laurin, my- 
ristin, arachin, buty- 
rin, lecithin, choles- 
terin. 
Relation of 
acids. 
Volatile acids rela- 
tively small; oleic 
acid, one-half non- 
volatile acids. 
Volatile acids rela- 
tively large, oleic 
acid small, palmitic 
and stearic large. 
Casein 
Precipitated with 
difficulty by salts 
and acids; easily 
soluble in acids; 
leaves no pseudo- 
nuclein with peptic 
digestion. 
Precipitated easily by 
salts and acids; pre- 
cipitate not easily 
soluble in excess of 
acids; leaves residue 
of pseudonuclein. 
Composition 
of proteids. 
Lactalbumin, lacto- 
globulin, and casein; 
ratio of casein to 
albumin, 1 to 2 (?). 
Lactalbumin and glob- 
ulin small; casein 
to albumin, 1 to 7, 
or even 1 to 10. MILK 
MILK, MODIFIED 
Properties. 
Human Milk. 
Cow's Milk. 
Mineral 
matters. 
Relatively small 
amount; contains 
one-sixth as much 
CaO and one-fourth 
as much P2O4 as 
cows' milk. 
Contains relatively 
large amount. 
Bacteria 
Generally sterile; rare- 
ly staphylococcus 
albus and aureus. 
Contains numerous 
bacteria, and occa- 
sionally typhoid, 
diphtheria, tuber- 
cular organisms, etc. 
Citric acid... 
About 0.05 per cent.. 
About 0.1 to 0.15 per- 
cent. 
Enzymes.... 
Amylase, lipase, and 
fibrin ferment. 
Amylase, oxidase, and 
proteolytic ferment. 
Milk is drawn into the pipet up to the mark 
"M" when it is emptied into the cylinder "C." 
The former is then at once rinsed with water 
and the washings added to the milk. While 
shaking, water is further added, until the 
black lines upon the milk-colored glass plug "A" 
can just be discerned. The figure upon the right 
of the scale which is reached by the mixture will 
then directly indicate the percentage amount of 
fat, while the number upon the left indicates 
the amount of water that has been added. See 
Colostrum. 
MILK, ARTIFICIAL. See Milk (Modified). 
MILK, DRUGS EXCRETED IN.-When taken 
during lactation, the following drugs are ex- 
creted in the milk: the oils of anise, cumin, dill, 
wormwood and garlic, turpentine, copaiba, the 
active principles of rhubarb, senna, scammony 
and castor oil, opium, iodin, indigo, antimony, 
arsenic, bismuth, iron, lead, mercury and zinc. 
Acids given to the mother cause griping in the 
child. Natural salts, as a rule, and the purgative 
agents above-named, act as purgatives to the child, 
and potassium salts as diuretics. Turpentine, 
copaiba and potassium iodid given to the mother, 
can be detected in the urine of the child. Opium 
given to the mother may narcotize the child, and 
mercurials in the same manner may salivate it. 
Atropin, hyoscyamin, the salicylates and potassium 
sulphid have been found in the milk after their 
ingestion by the woman. 
MILK, FILTERED.-It has been observed that 
milk carefully filtered through a thick layer of 
absorbent cotton is freed from dirt and, to a great 
extent at least, from germs, and the quality of the 
milk is in no way altered. In this process we have, 
therefore, a simple method of sterilizing milk for 
infants' food without the application of heat, 
which, no doubt, in many cases changes the 
nutritive quality, and is in certain instances a 
cause of scorbutus and other disorders of nutrition. 
Milk may be satisfactorily filtered by placing 
in a clean glass funnel a piece of absorbent cotton 
about an inch thick, and allowing the milk to per- 
colate through it into the nursing-bottle. 
MILK, MODIFIED.-The modification of cow's 
milk consists in changing the proportions of the 
different ingredients until they resemble as closely 
as possible those of mother's milk. The following 
table gives the average percentage of the different 
ingredients in cow's milk and mother's milk: 
Determination of Specific Grav- 
ity and Percentage of Fat.-The 
specific gravity of milk may be 
easily determined by a lacto- 
meter or "lactodensimeter" (such 
as Quevenne's). The tempera- 
ture of the milk should always be 
60° F. 
Estimation of Percentage of 
Fat.-For this the lactoscope of 
Feser is used. The process, as 
given by Simon, is as follows: 
Cow's Milk. 
Mother's Milk. 
Fats 
4 percent 
4 percent 
Sugar 
4.30 percent 
7 percent 
Proteids 
4.00 percent 
1.50 percent 
Salts 
0.70 percent 
0.20 percent 
Water 
87.00 percent 
87.30 percent 
Specific gravity 
1029 
1031 
Reaction 
Acid 
(not sterile). 
Alkaline 
(sterile). 
Quevenne's Lac- 
toden s 1 m e t e r.- 
(Simon's Clinical 
Diagnosis.) 
Feser's Lactoscope.- 
(Simon's Clinical Diag- 
nosis.) 
By referring to the foregoing table it will be 
noticed that in altering cow's milk to the standard 
of human milk the greatest differences to be over- MILK, MOTHER'S 
MILK, MOTHER'S 
come are in the proportions of the proteid elements, 
the salts, and the sugar; in cow's milk the two first 
being too abundant and the last deficient. In 
laboratories specially fitted up for the purpose 
milk may be modified exactly to any desired pro- 
portions, but in the household or nursery this is 
not possible, and we are obliged, therefore, to 
follow certain general and simple rules by which 
we may practically be able to adjust the milk 
to the child's digestive powers and furnish its 
system with the proper elements of nutrition. 
To accomplish this end, keeping in mind 
woman's milk as the standard, it is necessary: 
1. To reduce the proteids. This is done 
by adding water-as much or a little more water 
than we have milk. 
2. To increase the sugar, which at first was defi- 
cient, and by dilution has been made still more so. 
It is necessary to add about 10 grains of sugar 
to each ounce, or a heaping teaspoonful to each 
8-ounce feeding. Milk-sugar is usually recom- 
mended, but as it is more liable than cane-sugar, 
especially in hot weather, to cause fermentation, 
the latter is better for ordinary use. Whichever 
is used, it should be dissolved in a little hot water 
before being added to the milk. 
3. To add cream, which at first was sufficient, 
but has been much reduced by the water which has 
been added. It is necessary, to bring the fats up 
to the standard, to add about 1 1/2 to 2 teaspoon- 
fuls to each ounce, or 1 1/2 to 2 ounces of cream to 
each 8-ounce feeding. 
4. It is necessary to add an alkali-about 10 
grains of bicarbonate of sodium to an 8-ounce 
bottle. The salts, by dilution, have been reduced 
to about the standard. 
5. The milk must be freed from germs, which 
may be practically accomplished by filtering or, if 
preferred, by pasteurizing. 
Milk modified as above would be expressed in 
the following recipe for a child 6 or 7 months old: 
1$. Cream, 3 jss 
Milk, 3 iij 
Boiled water, 3 iijss 
Sodium bicarbonate, gr. x 
Sugar, 3 j. 
Mix, filter or pasteurize, heat to 98° F., and 
feed every 3 hours. 
See Modified Milk in Infant Feeding. 
MILK, MOTHER'S.-For table giving the aver- 
age percentage of the different elements of human 
milk, see Milk, and Milk (Modified). 
The color is bluish-white; taste, sweet. Micro- 
scopically may be seen great quantities of fat 
globules and, perhaps, a few epithelial cells. 
Slight coagulation is produced by adding acetic 
acid or digestants, such as liquid rennet; but when 
in a normal condition, it never coagulates in large, 
hard masses, as does cow's milk. 
The first 2 days after parturition the amount 
secreted is very small, but after 3 to 5 days there 
should be an abundant supply. Milk is formed 
to some extent in the gland all the time, but most 
plentifully while it is being stimulated by the 
child suckling. 
Colostrum is the secretion of the first 2 or 3 days, 
and it differs quite markedly from the later milk. 
It is a deep yellow color; is not so sweet as the later 
milk; has a specific gravity of 1040 to 1046; coagu- 
lates into a solid mass by heat; is very rich in pro- 
teids and salts, and has a laxative effect. Micro- 
scopically there are seen, besides the fat globules, 
arge numbers of granular bodies, known as colos- 
trum corpuscles, which gradually disappear from 
the milk by the end of a week or 10 days. See 
Colostrum. 
Tests.-When a child fed at the breast does not 
thrive, the milk should be tested. The specimen 
used should be the whole quantity, preferably, 
from a breast, as the quality varies according to 
the time it is taken, the first milk being poorer in 
fats and richer in proteids, and the last milk, or 
the strippings, being rich in fat and low in proteids. 
An easy clinical method of testing the milk is 
the following: 
Too high specific gravity shows excess of pro- 
teids. Too low specific gravity, excess of fats. 
The sugar and salts are practically constant. 
To ascertain the percentage of fats, take a cylin- 
der holding 10 c.c., graduated to 100 parts; fill to 
the 100 mark with the milk, and allow the cream 
to rise for 24 hours. The cream bears the relation 
of 5 :3 of the fat, so if the reading on the cylinder 
shows 7 of cream, the fats would equal three-fifths 
of 7, or 4.2 percent. 
Normal human milk will frequently vary con- 
siderably in the percentage of its elements and be 
at the same time abundantly nutritious to the 
child which is fed upon it. If the percentages are 
far from the average, however, and the child shows 
symptoms of inadequate nursing, much may often 
be done toward correcting the faulty condition by 
regulating the mother's mode of life, as regards 
her exercise and diet. As a general rule, it should 
be remembered that lean and rare meats and other 
albuminous foods will increase the fats, and exer- 
cise will reduce the proteids. Below are given 
some of the conditions which affect the secretion 
of the milk. 
1. Too frequent or prolonged nursing causes the 
milk to be poor and weak. 
2. Age.-A woman very young or over 40 is 
likely to have milk weak in cream and rich in 
proteids. 
3. Acute illness, except fevers of a severe type, 
do not alter the quality. Such fevers, however, 
will reduce the cream and increase the proteid con- 
stituent. 
4. Menstruation does not materially affect the 
quality. 
5. Pregnancy.-The milk of a pregnant woman 
is usually small in quantity and poor in quality. 
6. Drugs.-See Milk (Drugs secreted in). 
7. Nervous impressions, when marked, have a 
decided effect upon the milk. Fatigue, exhaustion, 
great excitement, sudden fright, grief, or passion 
may affect it so as to cause an acute indigestion 
only, or, in other cases, grave toxic symptoms, as 
high temperature, great prostration, or even con- 
vulsions. 
8. Diet.-Nitrogenous foods increase the fats and MINERAL WATERS 
MILK, PASTEURIZED 
proteids. Vegetable diet diminishes both the 
fats and proteids. A very low diet diminishes the 
fats and may either increase or diminsh the pro- 
teids. An excessively rich diet increases both the 
fats and proteids. Liquids increase the quantity. 
Alcoholic drinks or malt extracts, porter, etc., in- 
crease the quantity; also the fats and usually the 
proteids. 
9. Massage of the breasts is one of the most effi- 
cient means of stimulating the milk-supply. It 
should be done with great care and gentleness, and 
with every precaution against infection. The 
entire breast should be rendered aseptic, as should 
also the hands of the operator, and massage should 
be done 2 or 3 times a day. Some mild antiseptic 
ointment may be used with the massage. 
See Breast; Milk. 
MILK, PASTEURIZED.-By pasteurizing milk 
we mean heating it to a temperature of 140° to 160° 
F. for a period of 20 minutes. This process has 
been shown to be sufficient to destroy the germs 
(but not their spores) most commonly to be found 
in milk, as the bacilli of typhoid fever, cholera, 
diphtheria, tuberculosis, and the pus germs. Milk 
thus treated will keep 2 or 3 days in a room at the 
ordinary temperature, and on ice for several days. 
Milk heated to 167° F. has no objectionable taste, 
and it is thought that its digestibility and nutri- 
tional qualities are not changed. 
MILK, PEPTONIZED.-The following is a simple 
rule for peptonizing milk: In a clean glass jar con- 
taining 4 ounces of cold distilled or boiled water 
dissolve 15 grains of sodium bicarbonate and 
5 grains of pancreatin (extractum pancreatis), to 
which add 12 ounces of good milk. Set the jar in 
a vessel of water at a temperature of 105° to 115° 
F. for from 5 to 20 minutes to partially peptonize, 
and for-2 hours to completely digest or peptonize. 
MILK, PREPARED.-See Milk (Modified). 
MILK, STERILIZED.-Sterilized milk is that in 
which the germs have been destroyed by heat. 
This can be accomplished absolutely only by 
heating it to 212° F. or higher on 2 or 3 successive 
days, as in preparing a culture medium. The ordin- 
ary method of sterilizing is to place the milk in 
jars, which are then exposed to the action of steam 
for an hour and a half. Heating to so high a 
degree causes the quality of the milk to be changed, 
and it is therefore rendered unfit for infant's food, 
except as a makeshift in very hot weather when 
ice cannot be procured, or when it is necessary for 
it to be kept for a considerable time, as in traveling 
when fresh milk cannot be obtained. 
MILK LEG.-See Phlegmasia Alba Dolens. 
MILK SICKNESS (Trembles, Slows, Puking 
Fever).-An acute infectious disease prevailing in 
newly settled lands in the western and southern 
parts of the United States, transmitted to man 
through milk, cheese, butter, flesh of affected 
cattle. The specific cause is unknown. It is 
characterised by vomiting, trembling, constipa- 
tion, fetid breath, thirst and moderate fever. The 
disease is generally fatal. Treatment is sympto- 
matic and eliminative. 
MINERAL WATERS.-Natural water differs 
from distilled water in containing saline and other 
constituents in varying proportions; from common 
water, in which they are so small in quantity as 
not to alter the taste, color, etc., up to the sea- 
water, having 3 1/3 percent, and that of the Dead 
Sea, with 26 1/2 percent. Spring waters impreg- 
nated with foreign substances so as to have a 
decided taste and a marked action on the human 
system are called mineral waters, and may be 
subdivided into various groups, according to their 
prevailing constituents, as carbonated, alkaline, 
saline, sulphureted, silicious, etc. Full analyses 
of all the principal mineral waters of Europe and 
America are given in the fifteenth edition of the 
United States Dispensatory, but a few of the most 
prominent will be mentioned here. 
Alkaline Mineral Waters.-Ems, Germany; 
Salzbrunn, Germany; Gleickenberg, Austria; Vichy 
France; Vais, France; Bladon Spring, Ala.; Con- 
gress Spring, Cal.; Seltzer Spring, Cal.; St. Louis 
Spring, Mich.; Buffalo Lithia Spring, Va.; Hot 
Spring, Va.; Warm Spring, Va.; Berkeley Spring, 
Va.; Bethesda Spring, Wis.; Gettysburg Spring, Pa. 
These waters are generally cold, those of Vichy 
and Ems being warm. They contain a consider- 
able amount of sodium carbonate, also sodium 
chlorid and sulphate, and various other chlorids, 
carbonates, and sulphates, with carbonic acid gas 
in varying quantity. Vichy and Vais waters 
depend for their efficacy almost wholly on the 
quantity of sodium carbonate contained in them, 
which is for Vichy from 26 to 50 grains and for 
Vais about 60 grains to the pint. 
Saline Mineral Waters.-Freidrichshall, Ger- 
many; Hunyadi Jd,nos, Germany; Baden-Baden, 
Germany; Cheltenham, England; Kissingen, Ba- 
varia; Reichenhall, Bavaria; Wiesbaden, Germany; 
Carlsbad, Bohemia; Piillna, Bohemia; Seidlitz, 
Bohemia; Marienbad, Bohemia; St. Catherine's 
Ontario, Canada; Adelheidsquelle, Bavaria; 
Kreutznach, Prussia; Saratoga Springs, N. Y.; 
Ballston, N. Y.; Hot Springs, Ark. 
These waters are of more complex composition, 
the various waters of Saratoga containing more 
than thirty constituent salts. Those usually 
present are the sulphates and carbonates of sodium, 
calcium, magnesium, etc. (magnesian waters'); 
chlorids of sodium, potassium and lithium (chlori- 
nated waters); ferrous salts (chalybeate waters), 
with iodin, bromin, manganese salts, and phos- 
phates in some few. Carbonic acid gas is present 
in all. Most of them are purgative, some are con- 
sidered alterative, and many are warm (100° to 
160° F.). The most powerful of the saline group 
is the Hunyadi Janos, containing about 150 grains 
each of magnesium and sodium sulphates to the 
pint; it is effectively purgative. Piillna water is 
nearly as strong, with 124 grains of sodium sul- 
phate and 93 grains of magnesium sulphate to the 
pint. Friedrichshall is less powerful, but a better 
aperient water in 6- to 10-ounce doses. Marienbad 
contains no magnesium sulphate, but has 36 grains 
of sodium sulphate, 9 of sodium carbonate, 11 of 
sodium chlorid, and a small quantity of ferrous 
carbonate to the pint; in transportation it loses its 
carbonic acid and deposits the iron; in ordinary 
doses it is not aperient. Carlsbad water contains MIOSIS 
MIXTURES 
20 grains of sodium sulphate and 9 each of sodium 
carbonate and chlorid to the pint. "Carlsbad 
salt" is simply sodium sulphate with a trace of the 
carbonate. These waters are either imported or 
are made in the United States. 
Sulphurous Mineral Waters.-Aix-la-Chapelle, 
Prussia; Bareges, South France; Eux-Bonnes, 
South France; Llandrindrod, Wales; Harrowgate, 
England; Blue Lick Springs, Ky.; Sharon Springs, 
N. Y.; Yellow Sulphur Springs, Va.; White Sul- 
phur Springs, W. Va. 
These waters contain sulphureted hydrogen gas, 
also carbonic acid gas and carbonates, chlorids and 
sulphates of sodium, potassium, magnesium, and 
calcium; sometimes carbonate and oxid of iron, 
iodid and bromid of sodium. 
Carbonated Mineral Waters.-These waters are 
cold, contain generally carbonates of calcium, mag- 
nesium and sodium (in some, iron), which are held 
in solution by the excess of carbonic acid, also 
chlorids of sodium and postassium, sulphates, 
phosphates, etc. 
Silicious Mineral Waters.-Hot Springs, Iceland; 
and the geysers of Yellowstone Park. The constit- 
uents of these waters are chiefly alkaline silicates. 
Therapeutics.-An undue value is placed by the 
laity and interested proprietors upon the medicinal 
value of mineral waters. The benefit in most in- 
stances from them is due to change of climate and 
scene, freedom from business and home cares and 
worry, regularity of life and diet, drinking water in 
quantity, and, in many instances, the substitution 
of water for alcoholic beverages. Those springs 
which are furthest removed from the patient's 
residence, are, as a rule, of the most value to him, 
as similar invalids whose homes are in the vicinity 
of the springs are often not benefited by its water. 
The principal affections in which mineral waters 
are esteemed are the following: Cirrhosis of the 
liver, dyspepsia, gout, rheumatism, uricacidemia, 
lithiasis, hepatic diabetes, constipation, strumous 
disorders, obesity, plethora of the pelvic organs, 
hypochondriasis, skin-diseases, especially those 
dependent on gastric derangement, phthisis, con- 
stitutional syphilis, metallic poisoning, etc. 
Aperient and purgative waters are useful when a 
prejudice exists against purgative medicine. See 
Water, Gout, Rheumatism, Constipation, etc. 
MIOSIS.-Contraction or decrease in the size 
of the pupil. See Pupil. 
MIOTICS (Myotics).-Agents which cause the 
contraction of the pupil. They act by stimulating 
the motor oculi nerves supplying the circular mus- 
cular fibers of the iris, and produce this effect when 
locally applied or internally administered, except 
morphin, which acts centrally, and does not affect 
the pupil when applied locally. Physostigmin 
(eserin) is the chief miotic for local use, and the 
only one employed in ophthalmic practice. Others 
are muscarin, pilocarpin, and nicotin. Physos- 
tigmin also contracts the ciliary muscle, leaving the 
eye accommodated for the near point only, and 
lessens intraocular tension, antagonizing exactly 
the eye-actions of atropin. Morphin given inter- 
nally produces miosis by stimulation of the oculo- 
motor centers probably, the dilatation which 
occurs as death approaches being due to final 
paralysis of the same (Wood). The general anes- 
thetics dilate the pupil in the first and last stages of 
their action, but contract it in the middle stage, 
that of complete anesthesia. When in this stage 
dilatation occurs, it is a dangerous sign of failing 
respiratory power, unless it is accompanied by 
symptoms of returning consciousness, as reflex 
movements and vomiting. 
MIRYACHIT.-A peculiar disease observed in 
some Oriental tribes, the chief characteristic of 
which consists in mimicry by the patient of every- 
thing said or done by another. The same dis- 
ease is called lata by the Javanese. It is also 
allied to the disease of the "jumpers" of Canada. 
MISCARRIAGE.-The expulsion of the fetus 
between the fourth and the sixth months of preg- 
nancy. See Abortion. 
MISSED ABORTION.-Death of the ovum dur- 
ing the first few months of gestation, followed by 
symptoms of abortion, which gradually subside 
without expelling the uterine contents. The 
ovum may remain inside the uterus for an indefi- 
nite period. More frequently decomposition, 
resulting in some form of sepsis, will occur. The 
treatment should be complete removal of the 
blighted ovum. See Abortion. 
MISSED LABOR.-Retention of a dead fetus 
in the uterus for a variable period of time after 
the normal expiration of pregnancy. There are 
usually a few slight pains at term, which gradu- 
ally subside. Missed labor is most frequently 
the result of an extrauterine pregnancy that has 
advanced to term, or of pregnancy in one horn of an 
imperfectly developed uterus. It may be due to 
cicatricial contraction of the cervix. See Labor. 
MITRAL DISEASE.-See Heart-disease (Or- 
ganic). 
MIXED TREATMANT.-See Syphilis. 
MIXTURES (Misturae).-Aqueous liquid prep- 
arations intended for internal use, which con- 
tain suspended insoluble substances. The term 
"mixture" is used somewhat indiscriminately. 
There are four official mixtures, as follows: 
Title. 
Constituents. 
Properties 
and Dose. 
Mistura: 
Crete {chalk 
Compound chalk pow- 
Antacid, 4 
mixture). 
der, 20 gm.; cinnamon 
drams. 
Ferri composita 
water, 40 c.c.; water, 
sufficient to make 100 
c.c. 
Ferrous sulphate, 6 gm.; 
Tonic, 4 drams. 
{Griffith's 
mixture). 
Glycyrrhizse 
Myrrh, 18 gm.; sugar, 
18 gm.; potassium car- 
bonate, 8 gm.; spirit 
of lavender, 60 c.c.; 
rose water, sufficient to 
make 1000 c.c. 
Extract of liquorice, 30 
Expectorant, 2 
composita 
c.c.; syrup, 50 c.c.; 
drams (child, 
{Brown mix- 
acacia, 30 gm.; cam- 
phorated tincture of 
opium, 120 c.c.; wine of 
antimony, 60 c.c.; 
spirit of nitrous ether, 
30 c.c; water, sufficient 
to make 1000 c.c. 
1 dram). 
ture). MODIFIED MILK IN INFANT FEEDING 
MODIFIED MILK IN INFANT FEEDING 
Title. 
Constituents. 
Properties 
and Dose. 
Mistura; 
Rhei et Soda?... 
Sodium bicarbonate, 35 
gm.; fluidextract of 
rhubarb, 15 c.c.; fluid- 
extract of ipecac, 3 c.c.; 
glycerin, 350 c.c.; spirit 
of peppermint, 35 c.c.; 
water, sufficient to 
make 1000 c.c. 
Carminative. 
Dose, 1 dram. 
nature has given us more scientifically and ac- 
curately. Thinking of the elements of milk in 
percents is the simplest as well as the surest way 
of dealing with such a complex food. It is not, 
however, a method of feeding in itself, but of 
adapting the proper parts to the demands of the 
individual infant. Any successful method of 
feeding devotes its time to acquiring a com- 
plete understanding of the demands and needs 
of the individual infant. This is the most im- 
portant premise in infant feeding. There are no 
rules in infant feeding which a text-book or 
lecturer can give as absolute or infallible. 
Let it be understood, then, that the percentage 
system is not a method of feeding, but a scientific 
procedure of computing the ingredients which 
we are to use in our milk for feedings. 
The first step in the intelligent understanding of 
infant feeding is to know as accuarately as pos- 
sible the feeding history of the infant to be cared 
for. What food it has been having is hardly 
sufficient-a knowledge here of the exact amounts 
of each ingredient, how each of these has been 
assimilated and how excreted; the amounts at 
each feeding, and the intervals between* feed- 
ings; the source of the milk, whether dirty or 
clean, whether cooked or raw; the weight of the 
child, its average loss or gain in weight; all these 
are vitally necessary questions. The age of the 
child is of less importance and it is often of ad- 
vantage to form our judgments of the needs and 
powers of assimilation of the infant before we 
know its age. No rules can be based upon age 
alone. What the child should have as food depends 
on far more essential features than age. The 
physiologic development, the powers of assimila- 
tion, the individual response to outside energy, 
i. e., food, the powers of resistance, the equilibrium 
of the child in its relation to the outside world- 
these are the important features of the case. 
Every child is a law unto himself and only broad 
principles for treatment can be laid down. 
Cow's milk has the following average composi- 
tion according to Ko nig: 
Water, 87.7 
Casein, 3.0 
Whey proteid, 0.4 
F at, 3.7 
Sugar, 4.5 
Ash, 0.7 
Breast milk is composed of water, proteid, fats 
sugar and salts. The proteids, fats and sugar, 
vary widely even within normal limits during 
different periods of lactation and under various 
conditions, This is well shown by a comparison of 
different authorities: 
MODIFIED MILK IN INFANT FEEDING.- 
No susbtitute can compare with mother's milk for 
infant feeding; and next to mother's milk modified 
cow's milk is the best. Where cow's milk is not 
obtainable, the adaptation has been made from 
the animal which, in that region, can produce 
the most abundant supply of milk. Thus in 
certain places goat's milk or the milk of the ass 
may be used. Cow's milk in this country has 
always offered the best substitute in infant feeding. 
It contains the same ingredients as human milk, 
but in materially different proportions. The 
first attempts at feeding with cow's milk were 
made by simple dilutions with water. This 
procedure met with success in many instances, 
and continues to do so when a perfectly healthy, 
normal baby is the subject. But it was soon 
found that a certain percentage of infants thus 
fed developed indigestion. At first attention 
was focussed on the tough hard curds that these 
cases either vomited or passed in their movements. 
This was attributed to the higher amount of pro- 
teid that appears in cow's milk as compared with 
human milk. When simple dilutions failed, the 
fact that cow's milk differs slightly in its reaction 
from that of human milk-being amphoteric 
instead of alkaline-was considered to be the 
cause of such failures. Therefore lime water was 
added to all milk given to infants in order to over- 
come this slight acidity, or bicarbonate of sodium 
was added to produce a more marked alkalinity. 
Later on, pancreatizing, or peptonizing as it was 
then called, was used in special cases to facilitate 
digestion. Breaking up of the curds was also 
attempted by the use of cereal diluents which 
produced a fine division of the proteid matter in 
the milk mixtures. 
The first attempt to direct a more scientific 
spirit rather than empiric toward the question of 
infant feeding was in the comparative study of the 
different ingredients in human milk and cow's 
milk. The prevalent idea was that an exact re- 
production of the percentage composition of 
human milk would solve all the difficult problems 
in the use of cow's milk. This premise though a 
failure, has, as a scientific advance, proved a right 
step. The successes of percentage feeding have 
not been due to the often attempted and as often 
defeated plan of reproducing or imitating nature, 
but to the plan of adaptation. 
Present Understanding of Percentage Substitute 
Feeding.-To-day advocates of scientific accuracy 
in infant feeding make no attempt at blindly fol- 
lowing nature, but teach the use of the means 
Authorities, 
Proteid, 
percent. 
Sugar, 
percent. 
Fat, 
percent. 
Pfeiffer 
1.049-3.04 
4.20- 7.60 
0.70-9.00 
Johanesson and Wang... 
0.900-1.30 
5.90- 7.80 
2.70-4.60 
V. and J. Adriance 
0.230-2.60 
5.35- 7.95 
1.31-7.61 
Schlossman 
0.560-3.40 
5.20-10.90 
1.60-9,4" MODIFIED MILK IN INFANT FEEDING 
MODIFIED MILK IN INFANT FEEDING 
Under even these wide variations a breast-fed 
infant normally does perfectly well. 
The same variations occur from simple cow's 
milk, especially in the fats and proteids, accord- 
ing to Von Styke: Proteid, 2.19 to 8.56 percent; 
fat 2.25 to 9.00 percent. This can be almost 
wholly overcome by using the mixed milk for a 
herd when the variation ought never to be more 
than fat 3 to 5 percent; proteid 3 to 4 percent. 
But even minimizing these variations is often 
not enough. The different elements vary in the 
different breeds of cows. Jersey and Guernsey 
cows' milk is always higher in its fat percentage; 
and, what is more important, the form in which the 
fat is emulsified is different. In Jersey milk 
the fat globules are large and the emulsion coarse. 
The digestion and assimilation of fat so coarsely 
emulsified is very much more difficult than is the 
finer emulsification found in Holstein, Durham 
or Ayrshire breeds of cows. Therefore either 
a pure or a mixed herd from these breeds is best 
chosen for producing milk for infant feeding. 
The conditions under which the milk is produced 
plays an important part. Unless milk is produced 
under the most approved sanitary and hygienic 
conditions, such as are demanded by certified 
milk (10,000 bacteria to the c.c.), disastrous results 
may follow in the form of acute bacterial intestinal 
infections, to which is due a large part of the in- 
fant mortality, especially in our large cities. 
Hence first of all in infant feeding we must know 
the kind of milk we are to use, both as to its 
average composition and under what conditions 
it is produced. 
The individual ability for assimilation and diges- 
tion of the various constituents of milk differs 
with each infant. No rules can be laid down, 
but the following general principles (gained from 
scientific study) are of value. 
Amount of Feedings.-The amount given must 
depend on the size of the infant. At any age an 
infant's physiologic capacity exceeds what is 
called its anatomic gastric capacity. Mosen- 
thal's data give perhaps the best figures as to the 
amounts that can be given at a single feeding: 
At the end of the first month 115 c.c., a scant 4 ounces. 
At the end of the second month 125 c.c., a trifle more than 4 
ounces. 
At the end of the third month 145 c.c., a trifle less than 5 
ounces. 
At the end of the fifth month 170 c.c., a trifle les" than 6 
ounces. 
Intervals of Feeding.-This would rationally 
depend on the rapidity with which an infant 
empties its stomach. A breast-fed infant empties 
its stomach in from one and a half to two hours, 
because of the physiologic fact that human milk 
is prepared for its passage into the duodenum 
sooner than cow's milk, this latter requiring from 
three to three and a half hours. This is due to the 
complex processes that take place in the stomach 
during digestion. It has been shown that the 
weaker the food the more rapidly is the stomach 
emptied. In its physiologic activity, the stomach 
begins the secretion of rennin and hydrochloric 
acid a few minutes after milk first enters so that 
the coagulation of the casein is finished in a few 
minutes after milk enters the stomach; the liquid 
part of the food, water, sugar, and salts are rapidly 
passed on into the duodenum. The esophageal 
orifice remains open as long as the contents of the 
stomach are alkaline and closes when they become 
acid. Whereas the pyloric orifice responds to 
exactly the opposite reaction, opening when the 
fluid portions coming in contact with it are acid, 
and closing when they are alkaline. The effect 
is the opposite in the reaction on the duodenal side 
of the pyloric orifice, which permits of an opening 
only when the duodenal contents are alkaline. 
The pyloric orifice reacts by closure to any but 
finely divided particles, making it difficult for the 
stomach to empty itself when digesting the more 
resistant curds formed from cow's milk. It takes 
longer for an acid reaction to appear because 
casein predominates to such an extent in cow's 
milk that the appearance of hydrochloric acid is 
delayed for two or three hours after the coagulation 
of cow's milk. After taking human milk, the hy- 
drochloric acid appears between forty minutes and 
one hour and a half. 
The capacity in the healthy infant for digesting 
and assimilating casein, whether human or cow's 
appears to be about equal. The difference in the 
two proteids comes from the great variation in 
proportion in which the whey proteids and the 
casein exist in the two milks. The proportion in 
human milk is almost 1 to 1, while in cow's milk 
it is 1 to 6. And this difference is the more im- 
portant when we appreciate the biologic work 
on the colloidal properties of milk done by Alex- 
ander and Bull on the difference of the two pro- 
teids. Colloids are of two classes. One is 
readily coagulated when it comes in contact 
with electrolytes, such as hydrochloric acid, and 
after being acted on or coagulated is not recon- 
vertible. These are called irreversible or unstable 
colloids. Casein belongs to this class. 
The other class can be redissolved after dessica- 
tion and is not affected by electrolytes. They 
further have the property of protecting the ir- 
reversible colloids from the action of electrolytes. 
The importance of whey mixtures in certain cases 
where the electrolytic action is too strong or where 
there is need of protecting the casein from too 
rapid coagulation is easily comprehended. And 
this biologic fact explains more clearly why we 
have such a fine flocculent coagulum formed in hu- 
man milk as compared with the tougher coagulum 
or curd found in cow's milk from the action of 
hydrochloric acid. At present it is even being 
questioned whether "Casein Curds" are ever due 
to the casein in cow's milk. It has been argued 
that because there is no relation between the 
nitrogen content of the food and the nitrogen con- 
tent of the stools "casein curds" do not point to pro- 
teid indigestion. However, Talbot has proved by 
indisputable biologic methods that cow's casein 
does appear in the so-called "casein curd." 
And there can be little question clinically that 
casein indigestion does exist and can be produced 
experimentally in certain cases by the addition 
of fat-free milk. In some cases the addition of 
even an ounce of fat-free milk will be sufficient MODIFIED MILK IN INFANT FEEDING 
to produce tough curds in the movements, whereas 
the addition of whey would have no like effect. So 
it may be safely said that although the proteid 
element in milk will cause us the least amount of 
trouble in substitute feeding, yet it can and does 
cause definite trouble if not properly managed, 
and may do considerable damage if the symptoms 
are not recognized and the casein element dimin- 
ished low enough to check the formation of curds. 
Whey may even be the portion of the proteid at 
fault as shown by Meyer's experiment of sub- 
stituting cow's whey to a mixture of mother's 
casein and fat, which caused an intestinal upset 
that did not occur when mother's whey was used 
in combination with cow's casein and fat. 
The digestion of fats in infants is a still more 
complex problem. Schwartz has shown that the 
fat globules of cow's milk are rolled together in 
large clusters and clumps and that the fat globules 
are surrounded by a zone of clear substance called 
periglobular substance, which in cow's milk is 
easily broken through, allowing the globules to 
flow together into larger clusters. In human 
milk, the globules are much finer and more evenly 
distributed about the field and the periglobular 
substance is not as easily broken through. Upon 
heating, the periglobular substance in cow's milk 
seems to become more elastic and the fusion of the 
fat droplets much less easily accomplished. This 
may account for the greater digestibility of heated 
cow's milk over raw cow's milk in some cases. 
These mechanical differences certainly play im- 
portant roles, but there are some chemical and 
physiologic differences which are of great im- 
portance. There is more oleic acid found in human 
milk which has a lower melting point than fatty 
acids found in cow's milk (100 to 102° F. in 
human; 104 to 106° F. in cow's). In human 
milk there are lesser amounts of volatile acids, 
and the iodin combining power is higher in 
human milk-30 to 50 percent-while it is only 
20 to 30 percent in cow's milk. Fat is also 
the last element to leave the stomach and in 
several instances more fat has been recovered 
from the stomach contents than had been taken in 
the previous 24 hours. With an excess of fat in 
the food, which at present we can only regulate 
quantitatively, we are not in a position to do any- 
thing but reduce the total amount. Future investi- 
gations will undoubtedly explain many things and 
point out how we can better adapt the fat of cow's 
milk to the infant's digestive capacity. One 
thing we have learned is that, normally, any per- 
centage above four is fraught with danger, and in 
the infant below normal a much smaller percent- 
age is alone safe even though there is no sign of fat 
intolerance or insufficiency shown in the stools. 
Uffenheimer claims that all the necessary ferments 
exist from the first in infants, so that it is possible 
that starches can be broken down and the double 
sugars split into simple sugars, in which condition 
alone can they be absorbed from the very first. 
Milk sugar has the slowest ratio of absorption. 
The amyolytic action of saliva is very weak before 
the sixth month, but after that time it increases 
rapidly until at the tenth month the action is 
MODIFIED MILK IN INFANT FEEDING 
double the strength of that at birth. From then 
until the fourth year there is very little gain in 
strength. Sugars and starch cause little trouble 
in the normal infant, but they may become very im- 
portant and disturbing elements if the fat assimi- 
lation is much disturbed. According to Finkelstein, 
sugars and starch together with the salts may be- 
come the most important factors in alimentary 
decomposition and intoxication. "Sugar," says 
Finkelstein, "is the element that produces the 
temperature in these cases of decomposition." 
The importance of salts in metabolism has been 
increasing steadily as our appreciation of their 
intimate relation and significance in vital 
processes has become more exact. Human 
milk supplies less salts than cow's milk, but 
the amount of salts that is capable of ab- 
sorption in human milk exceeds that in cow's 
milk by about 20 percent. And the amount 
retained varies even more, being about 40 to 50 
percent for human milk and only 15 percent for 
cow's milk. When there is fat intolerance the 
salts appear in the stools as soaps, and the loss of 
these salts cannot be made up by the addition of 
salts to the feeding. The salts principally affected 
are calcium and magnesium. These salts are also 
changed into insoluble forms by heating, and this 
important fact may explain the objection to heated 
milk when there is need of salts in the infant's 
metabolism. The rate and amount of absorption 
also changes during any illness, especially intesti- 
nal, though the extent of these changes has not 
been worked out, but their close relation to the 
weight curve when given in sufficient or insufficient 
amounts is fairly indicative of their importance. 
The next few years will probably see many changes 
in the knowledge of their exact and relative im- 
portance. It is necessary for us to consider these 
more scientific findings of late years as dominant 
factors in any attempt at feeding infants. We 
must understand the physiologic processes in an 
infant, and appreciate as fully as our present 
knowledge will allow us to do what these physio- 
logic powers will permit in the digestion of the 
different food stuffs which we give in cow's milk. 
Besides appreciating these physiologic facts of 
digestion we must also understand the needs of 
each individual child. An infant needs nourish- 
ment for more purposes than an adult. The 
necessity for growth is far greater in infancy than 
at any other time. This body substance can 
alone be supplied by the proteid or nitrogen 
element in cow's milk. The younger the child 
the higher is the percentage of nitrogen that can be 
utilized. This varies greatly in health and dis- 
ease. It is undoubtedly less during sickness, but 
may even exceed the normal during convalescence. 
Proteid also goes toward the repair as well as the 
building up of the body, and under certain con- 
ditions it may lend itself to furnishing body heat 
and energy, though when used for this it is far 
from being an economical process, as over 25 per- 
cent is not available for body heat and is given off 
as free heat. This function of supplying heat and 
energy is better supplied by the carbohydrate 
portion of the diet which has the same value per MODIFIED MILK IN INFANT FEEDING 
gram as the proteid, but is far more easily and 
completely vitalized and protects the wasteful 
combustion of proteid more than any other ele- 
ment. Heat and energy are supplied to a far less 
degree by the fats, which, however, go toward the 
increase in weight and stored-up energy. Just 
how this is accomplished is not perfectly clear nor 
is it known in what proportions the fats are carried 
through the blood and lymph. 
In determining the needs of an infant, there- 
fore, its weight is an important factor and, except 
during the time of sickness when the weight is 
less, fairly represents the physiologic stage of 
development. It must also be remembered that 
during convalescence from acute infections other 
than alimentary disorders the needs and power of 
assimilation may far exceed that indicated by the 
weight. At such a time the age plus the approxi- 
mate normal needs is a better guide in determin- 
ing the immediate needs of the infant. It has 
been generally accepted that during the first two 
or three months 110 calories per kilo are needed, 
that from the third to the sixth month 100 calories 
suffice, and from the sixth to the twelfth' month 
from 90 to 80 calories are needed. The demand 
for body growth on the proteids in the early 
months has been noted. This is calculated to 
amount to about 7 percent of the caloric need 
during the first year, or it may be even more since 
the utilization of cow's proteid is probably not as 
great as human. 
In estimating the energy quotient of the differ- 
ent elements found in milk, Rubner's figures are 
accepted. 
1 calorie is the amount of heat necessary to 
raise 1 liter of water to 1 degree Centigrade, and, 
according to Rubner, 
1 gram of fat yields 9.3 calories, 
1 gram of carbohydrates yields 4.1 calories, 
1 gram of proteid yields 4.1 calories, 
Or, if we wish to use ounces and quarts, 
1 ounce of fat yields 288 calories, 
1 ounce of carbohydrates yields 123 calories, 
1 ounce of proteid yields 123 calories, 
Or 
1 percent of proteid in 1 ounce of mixture will 
yield 1.23 calories, 
1 percent of carbohydrates in 1 ounce of mix- 
ture will yield 1.23 calories, 
1 percent of fat in 1 ounce of mixture will yield 
2.88 calories. 
So that taking milk at 3.50 percent proteid, 
4.75 percent carbohydrates, and 4 percent fat, we 
have about 20 calories to the ounce, or about 670 
calories to the quart. Fat free milk or skimmed 
milk will yield about 400 calories per quart, while 
gravity cream (16 percent) will yield 860 calories 
per pint. 
It will be apparent to any student of the sub- 
ject that a complete understanding of an infant's 
needs cannot be met simply by supplying a suffi- 
cient number of calories irrespective of the quan- 
tity of each ingredient used. The physiologic 
capacity of the infant must be gauged, its power 
of assimilation studied and the particular individ- 
ual element appreciated. In judging the powers 
MODIFIED MILK IN INFANT FEEDING 
of assimilation the stools are an important factor 
from two different standpoints; first of all, macro- 
scopic, chemical and microscopic study must be 
carried out if we wish to know whether digestion 
is normal. The stools of a normal infant are one 
or two yellow, soft, homogeneous ones. If there 
is an excess of proteid, the stools are a brownish 
yellow color, with a cheesy odor, and have an 
alkaline reaction. Tough casein curds the size of 
kidney beans may appear which are insoluble in 
ether and are hardened by formalin. When there 
is an excess of starch in the food, the movements 
are a darker brown color, have an aromatic acid 
odor, and an acid reaction. This excess of starch 
tends to increase the bacterial fermentation and 
may produce the excessive scalding so often seen 
in intestinal fermentation with loose movements. 
Starch granules may also be found by chemical 
examination. The fat stools are pale gray, soft, 
slimy, or green with small soft curds which give 
the characteristic chemical reactions and pictures 
of neutral fat globules or fatty acid crystals or 
fatty soaps. 
On the other hand, the importance of the intes- 
tinal flora and the influence of the different ele- 
ments of food on their activity are only now becom- 
ing evident. In this the sugars undoubtedly play 
a big part and their balance with the proteid con- 
stituent is an important element in whether fer- 
mentative or putrefactive processes will predomi- 
nate or whether the normal equilibrium will be 
maintained. 
In order to accomplish these results with any 
assurance of success we must think of the different 
elements that enter into feeding in the most exact 
terms, which are percents. Otherwise our special- 
ized knowledge will not carry us as far on the road 
to success as we are entitled to go. The processes 
in calculating these percents may be as simple or 
as complex as we wish to make them. The simpler 
we make them the more serviceable they will be, 
but the accuracy, and ability to get whatever per- 
cents of the various elements we need to meet the 
demands of each case must not be sacrificed to our 
ease in giving directions. 
If we take cow's milk to be on the average 
fat 4.00 percent, sugar 4.75 percent and proteid 
3.50 percent; and gravity cream to be fat 16 per- 
cent, sugar 4.50 percent, proteid 3.20 percent; fat- 
free or skimmed milk to be fat 0.0 percent, sugar 
4.50 percent, proteid 3.20 percent, they wall give 
us fairly constant and accurate averages in mak- 
ing up mixtures from the mixed milk of a good 
herd. If we wish to compute any desired formula 
the process is a very simple one and the necessary 
figures to remember are brought down to a mini- 
mum. Thus if we wish to feed a child ten months 
old, weighing 22 pounds, a mixture composed of 4 
percent fat, 7 percent sugar and 1.50 percent pro- 
teid, 8 ounces at a feeding and 5 feedings in 24 
hours, we would have the following example: 
4/16 of 40 (ounces in total mixture) = 10 ounces 
of 15 percent cream would give 4 percent fat. 
10 of 16 percent cream would also yield 10/40 of 
3.20, the proteid in 16 percent cream or .80 per- 
cent of proteid. MODIFIED MILK IN INFANT FEEDING 
MODIFIED MILK IN INFANT FEEDING 
10 ounces of 16 percent cream would also yield 
10/40 of 4.50 sugar in 16 percent cream or 1.12 
percent sugar. So that 10 ounces cream would 
furnish 4 percent fat, 1.12 percent sugar and 0.80 
percent proteid, and this subtracted from the orig- 
inal amount wanted would give what was still 
needed or 0.0 percent. 
4= percent of fat wanted . . . , • . 
- :- - of 40 = ounces m total mixture. 
16=percent of cream used 
= 10 ounces of 15 percent cream, which gives 4 percent 
fat. 
10 ounces of 16 percent cream would also yield 
10/40 of 3.20 (percent of proteid) in 16 (percent 
cream) or .80 percent proteid. 
10 ounces of 16 percent cream would also yield 
10/40 of 4.50 (percent of sugar in 16 percent cream) 
or 1.12 percent sugar, so that 10 ounces of cream 
would furnish 4 percent fat; 1.12 percent sugar; 
0.80 percent proteid, and this subtracted from the 
original amount wanted would give what was still 
needed or fat 0.0 percent; 5.90 percent sugar; 0.70 
percent proteid. .70 percent proteid is derived 
from the fat-free milk or skimmed milk which has 
a working percentage of 
Fat 0.0 percent; sugar 4.50 percent; proteid 3.20 
percent. 
We need then 
.70 (percent of proteid needed) 
3.20 (percent of proteid in fat-free milk 
= 8.75 ounces of fat-free milk. 
8.75 ounces of fat-free milk contains not only 
.70 percent of proteid, but also 
8.75 (ounces of fat-free milk) „ „ . 
;-r of 4.50 (percent of sugar m 
40 (total quantity) 
fat-free milk). 
=.97 percent sugar. 
In 8.75 ounces of fat-free milk so far we have 
Fat Sugar Proteid 
4 % 1.12 .80 % from .10 oz. of 16 % cream 
0 .97 .70 " 8.75 " " fat-free milk 
4% 2.09 1.50 % 18.75 
5 percent of sugar is still needed, which can be 
obtained in the following way: 
5 percent of 40 (total ounces in mixture) = .05 x 
40 = 2 ounces of sugar of milk, or 4 tablespoons of 
sugar. 
21.25 ounces of water is needed to bring up the 
total amount to the required 40 ounces. 
The caloric value of this food would be figured 
as follows: 
Mixture =4-7-1.50 40 ounces = (1200 c.c.) 
4 percent fat =.04 x9.3x1200 =446.4 calories. 
7 percent sugar = .07 x4.1x1200 = 344.4 calories. 
1.5 percent sugar = .015x4.1x1200 = 73.8 calories. 
Total, 864.6 calories. 
The caloric need of an infant weighing 22 
pounds in its tenth month would be about 85 
calories per kilo or 850 calories. This mixture 
then would just about satisfy the caloric needs of 
this infant. 
When whey mixtures are needed the same plan 
of computing the necessary amounts are carried 
out as follows: 
Mixture wanted: Fat, Sugar, Proteid 
3 6 90 whey- 
50 casein 
40 oz. in total mixture. 
Using 16 percent cream we have 
3/16 of 40 = 7.5 ounces cream =3 percent fat. 
• i 7.5 
7.5 ounces of 16 percent cream furnishes 
40 
of 3.20 (percent of proteid in 16 percent cream) = 
.60 proteid, and as 5/6 of this is casein we have the 
total amount of casein needed and .10 percent of 
whey is furnished. 
We still need .80 (percent of whey proteid) of 
40 which equals 32 ounces of whey. 
7.5 ounces of cream + 32 ounces of whey = 
39.5 ounces amount furnished by cream and whey. 
39 5 
of 4.50 (percent of sugar in whey and 
40 
cream) =4.50 percent sugar furnished, which 
leaves 1.5 percent of sugar still needed to complete 
the amount needed, which equals .015x40 = ^ of 
an ounce of sugar or about 1 1/4 tablespoons of 
sugar of milk. 
Therefore we have Cream, 7.5 ounces. 
Fat-free milk, 0.0 ounces. 
Whey, 32.0 ounces. 
Sugar, 1.25 tablespoonfuls. 
Boiled water, 0.5 ounces. 
The calories furnished by such a mixture would 
be: 
From the cream, .03x9.3xl200(c.c.) =335 calories 
From the proteid .074x4.lxl200(c.c.) =364 calories 
and sugar, A total of 699 calories 
The question of alkalinity has been a much dis- 
cussed one but, as stated before, has been very 
much overestimated. The addition of lime water, 
besides acting as a mild alkali, stimulates the 
secretion of hydrochloric acid, so that when lime 
water is added the total amount of hydrochloric 
acid is increased and there is very little protective 
power from the lime water unless given in large 
proportions. The amount added should always 
be calculated with reference to the amount of 
cream and milk in the mixture and not with refer- 
ence to the total amount of the mixture. The 
calculated maximum percent to produce a mild 
neutralization of the hydrochloric acid secreted 
by the stomach is 20 percent of the milk and 
cream, which delays the coagulation of the casein, 
giving a longer time for the protective action of the 
albuminoid portions of the proteid to affect some 
colloidal action on the casein, and so further 
delaying the coagulation and helping finally to a 
more rapid evacuation from the stomach because 
of the smaller size of the coagulum formed. A 
percentage of 50 to the amount of milk and cream 
suspends totally the action of the gastric digestion 
by hydrochloric acid and hastens the emptying 
of the stomach contents into the duodenum. 
Sodium bicarbonate acts even more strongly in 
neutralizing the hydrochloric acid, but exerts no 
stimulation on the hydrochloric acid secretion of MOLDS 
MONSTROSITY 
the stomach. It requires 0.68 percent of the milk 
and cream used to facilitate this neutralization, 
and 1.70 percent to suspend all action of the 
hydrochloric acid on the proteid in the food, and 
so hasten the contents into the duodenum. 
Sodium citrate appears to be the ideal protector 
of casein. For, as has been pointed out before, it 
has a definite protective action on the casein, being 
itself a stable colloidal substance with the power 
of protecting unstable colloids of the casein class, 
and sodium citrate also combines with hydro- 
chloric acid to forjn sodium chlorid and so lessens 
the available hydrochloric acid. Two grams to 
the ounce of milk and cream used is needed to 
accomplish this, and double this amount in cases 
with hyperchlorhydria. For this same purpose 
a small percentage of gelatin, 1 to 2 percent 
of the amount of milk and cream in the mixture, 
can be used as also can decoctions of any of the 
cereal grains. These weak decoctions from 
barley, oats, rice, and other cereals contain the 
colloidal portions of the proteid in these grains 
without much of the starch. After the 6 months 
when, as has been seen, starch digestion begins to 
become useful, the cereal flours can be made use of 
and they will furnish a slight amount of nourish- 
ment, especially if used in the strength of 3 percent 
for the diluent in our mixtures, so serving a double 
purpose. They may act also mechanically in the 
aid of constipation when there is very little choice 
among the different cereals. The conversion of 
starch is first into dextrin and then into maltose. 
The assimilation of the different sugars varies 
greatly. Lactose (milk sugar) is the least con- 
vertible, whereas maltose is the most easily con- 
vertible into dextrose, the body sugar, forming two 
molecules of dextrose, while lactose is capable of 
forming but one of dextrose and one of galactose. 
It is not surprising then that the effect on weight 
is greater from the use of the more easily convert- 
ible and assimilable sugars, as cane and malt or 
even of starch. When prepared with this in 
view-which means careful dextrinization easily 
accomplished in an hour by the addition of 
takadiastase-its food value is increased in pro- 
portion to the amount of malt converted into 
dextrose. See Infant Feeding, Milk, etc. 
MOLDS.-See Parasites (Vegetable). 
MOLE.-1. A proliferative degeneration of the 
chorionic villi, producing a mass of berry-like 
vesicles attached to the placenta. It is called 
vesicular mole, and hydatidiform or myxomatous 
degeneration of the placenta. See Chorion. 
2. Also applied to a small, pigmented spot of the 
skin. See Nevus. 
MOLLITIES OSSIUM.-See Bone Diseases. 
MOLLUSCUM CONTAGIOSUM.-An epithelial 
disease characterized by pinhead-sized to pea- 
sized or larger, smooth, semiglobular, waxy-white 
or pinkish elevations. The disease is uncommon. 
Etiology.-The disease occurs chiefly in the 
children of the poorer classes. It is probably 
contagious. 
Pathology.-The disease consists of an enormous 
hyperplasia of the cells of the rete mucosum, the 
process, in all probability, beginning in the hair 
follicles. The center of the molluscum tumor 
is made up of a number of lobules filled with 
ovoid or rounded, fatty looking, degenerated 
epithelial cells, designated as "molluscum bodies." 
Symptoms.-The lesions are discrete, usually 
split-pea-sized, of the color of the skin or pinkish, 
with often a distinct waxy appearance. The 
summits are somewhat flattened, and contain a 
central, darkish opening, from which a cheesy secre- 
tion may be expressed. They are usually situated 
upon the face, particularly about the eyelids, 
cheeks, and chin. They increase slowly in size, 
eventually terminating in suppuration and dis- 
integration. As a rule, no scarring is left. The 
lesions are few, a half dozen or more being the 
usual number present. 
Diagnosis.-The characteristic features of the 
disease are: The size of the lesions; their waxy 
appearance; the presence of a central orifice giving 
exit to a whitish secretion; and the history and 
course of the affection. 
Prognosis.-The condition sometimes disappears 
spontaneously. It is readily amenable to treat- 
ment. 
Treatment.-The tumors may be destroyed by 
incision, expression of their contents, and cauteri- 
zation of the cavity with the stick of nitrate of 
silver. Again, they may be curetted away or 
snipped off with a pair of curved scissors. Pe- 
dunculated growths may be ligated. When the 
lesions are small, the following ointment may be 
used: 
I|. Ammoniated mercury, 3 j 
Ointment of zinc oxid, g j. 
MONK'S-HOOD.-See Aconite. 
MONOMANIA.-A form of mania or madness in 
which a single delusion or form of delusion is 
especially dwelt upon. See Mania, Paranoia. 
MONOPLEGIA.-Paralysis of a single limb or 
of a single set of muscles. See Paralysis. 
MONOTAL.-Guaiacol methylglycholate. It is 
said to have the action of guaiacol without being 
irritant or toxic. It is recommended as an analge- 
sic for local application to painful areas of the 
skin, which readily absorbs it. 
MONSEL'S SALT, and SOLUTION.-See Iron. 
MONSTROSITY.-A teratism; a fetus or being 
with an abnormal development or superfluity 
or deficiency of parts or some vice of conformation. 
These may be compound or double, single or simple, 
according as the monster is composed of the mal- 
formations of one or more elementary organisms. 
A table of monstrosities is appended. 
According to Geoffroy Saint-Hilaire, Altered by 
Hirst and Piersol. 
TABLE OF MONSTROSITIES* 
HEMITERATA. 
I. ANOMALIES OF VOLUME. 
A. Of Stature. 
1. General diminution, as in a dwarf-delayed 
growth. 
2. General increase, as in a giant-precocious devel- 
opment. 
* Reproduced from "Human Monstrosities," by Barton 
Cooke Hirst, M. D., and George A. Piersol, M. D., Phila- 
delphia: Lea Brothers and Co., 1892. MONSTROSITY 
MONSTROSITY 
B. Of Volume (strictly speaking). 
1. Local diminution, affecting- 
(a) Regions, as a limb. 
(b) Systems, as undeveloped muscles. 
(c) Organs, as small breasts, stenosis of canals, 
etc. 
2. Local increase, affecting- 
(a) Regions, as the head. 
(6) Systems, as the adipose tissue. 
(c) Organs, as large breasts in women, lactiferous 
breasts in men. 
II. ANOMALIES OF FORM. Single order, including- 
deformed heads; anomalies of shape of the stomach; 
deformed pelves, etc 
III. ANOMALIES OF COLOR. 
A. Deficiency, complete, partial, or imperfect albinism. 
B. Excess, complete, partial, or imperfect melanism. 
C. Alteration, as in umlsual color of the iris. 
IV. ANOMALIES OF STRUCTURE. 
A. Deficiency in consistency, as cartilaginous conditions 
of bones. 
B. Excess in consistency, as anomalous ossification. 
V. ANOMALIES OF DISPOSITION. 
A. By Displacement. 
1. Of the splanchnic organs, as anomalous direc- 
tion of heart or stomach, hernias, exstrophy of 
the bladder, etc. 
2 Of the nonsplanchnic organs, as club-foot, cur- 
vature of the spine, misplaced teeth, misplaced 
blood-vessels, etc. 
B. By Change of Connection. 
1. Anomalous articulations. 
2. Anomalous implantations, as teeth out of line. 
3. Anomalous attachments, as of muscles and liga- 
ments. 
4. Anomalous branches, as of arteries and nerves. 
5. Anomalous openings, as of veins into the left 
auricle, of the ductus choledochus in an un- 
usual situation, of the vagina into the rectum, 
of the rectum into the male urethra, of the 
rectum at the umbilicus, cloaca. 
C. In Continuity. 
1. Anomalous imperf'orations, as of rectum, vulva, 
vagina, mouth, esophagus. 
2. Anomalous union of organs, as of kidneys, tes- 
ticles, digits, teeth, ribs; adhesion of the tongue 
to the palate. 
D. By closure, as in complete transverse septum in 
the vagina. 
E. By Disjunction. 
1 Anomalous perforations, as persistence of fora- 
men ovale, ductus arteriosus, urachus. 
2. Anomalous divisions, as splits, fissures in various 
organs, harelip, hypospadias, fissured tongue, 
cleft palate, fissured cheek. 
VI. ANOMALIES OF NUMBER AND EXISTENCE. 
1. By numerical defect, as absence of muscles, 
vertebrae, ribs, digits, teeth, a lung, a kidney, 
the uterus, the bladder, etc. 
2. By numerical excess, as supernumerary digits, 
ribs, teeth, breasts, a double uterus. 
1. Internal pseudohermaphrodites. Development of 
uterus masculinus. 
2. External pseudohermaphrodites. External geni- 
tals approach the female type; the monstrosity 
presents a feminine appearance and build. 
3. Complete pseudohermaphrodites (internal and 
external). Uterus masculinus with tubes; sep- 
arate efferent canals for bladder and uterus. 
(6) Female pseudohermaphrodites (with ovaries). Per- 
sistence of male sexual parts. 
1. Internal hermaphrodites. Formation of vas def- 
erens and tubes. 
2. External hermaphrodites. Approach of the ex- 
ternal genitals to the male type. 
3. Complete hermaphrodites (internal and external) 
Masculine formation of the external genitals 
and of a part of the sexual tract. 
CLASS I.-SINGLE MONSTERS. 
Order I.-Autositic Monsters. 
MONSTERS. 
( Phocomelus 
Hemimelus 
| Micromelus 
. Ectromelus 
Species 1. Ectrome- 
lus. 
Genus I, 
Symelus 
Uromelus 
Sirenomelus 
Species 2. 
Single species, Cel- 
osoma. 
Aspalasoma 
Agenosoma 
Cyllosoma 
Schistosoma 
Pleurosoma 
Celosoma 
Genus II, 
Notencephalus 
Proencephalus 
Podencephalus 
Hyperencephalus 
Iniencephalus 
Exencephalus 
Species 1. Exen- 
cephalus. 
Genus III, 
Species 2. Pseuden- 
cephalus. 
Nosencephalus 
Thlipsencephalus 
Pseudencephalus 
Species 3. Anen- 
cephalus. 
Derencephalus 
Anencephalus 
Species 1. Cyclo- 
cephalus. 
Ethmocephalus 
Cebocephalus 
Rhinocephalus 
Cyclocephalus 
Stomocephalus 
Genus IV, 
Sphenocephalus 
Octocephalus 
Edocephalus 
Opococephalus 
Triocephalus 
Species 2. Octoceph- 
alus. 
HETEROTAXIS. 
Order II.-Omphalositic Monsters. 
Species 1. Para- 
cephalus. 
Paracephalus 
Omacephalus 
Hemiacephalus 
I. Splanchnic Inversion. 
II. General Inversion. 
HERMAPHRODITES.* 
Genus I, 
Species 2. Aceph- 
alus. 
Acephalus 
Peracephalus 
Mylacephalus 
I. True Hermaphrodites. 
(a) Bilateral hermaphrodites. 
(h) Unilateral hermaphrodites. 
(c) Lateral hermaphrodites. 
II. Pseudohermaphrodites, with double sexual forma- 
tion of the external genitals, but with unisexual 
development of the reproductive glands (ovaries 
and testicles). 
(a) Male pseudohermaphrodites (with testicles). 
Species 3. Asomata. 
Genus II, Single species, Anideus. 
CLASS II.-COMPOSITE MONSTERS. 
Order I.-Double Autositic Monsters.* 
* The third order of Geoffroy Saint-Hilaire, single parasitic 
monsters, under which name he describes dermoid cysts, is 
omitted, Forster's classification is substituted, with slight 
modification, for that of Geoffroy Saint-Hilaire. 
* Klebs' classification of hermaphrodites, as given by 
Ahlfeld, is substituted for that of Geoffroy Saint-Hilaire. MORBILLI 
MOSQUITOS 
A Terata katadidyma. 
Genus I, Diprosopus 
Genus II, Dicephalus 
Genus III, Ischiopagus 
Genus IV, Pygopagus 
B Terata anadidyma. 
Genus I, Dipygus 
Genus II, Syncephalus 
Genus III, Craniopagus 
C. Terata anakatadidyma. 
Genus I, Prosopothoracopagus 
Genus II, Omphalopagus 
Genus III, Rhachipagus 
Order II.-Double Parasitic Monsters. 
are of medical interest, Culex, Stegomyia, and 
Anopheles. The following table (by Jackson) will 
be found helpful: 
Culex. 
Stegomyia. 
Anopheles. 
Diseases 
convey- 
ed. 
Mostly nonpatho- 
genic for man 
but nay convey 
filarial diseases. 
Stegomyia fas- 
ciata conveys 
yellow fever in 
man. 
Conveys mala- 
r i a 1 disease. 
Conveys fila- 
rial disease in 
man. 
Breeds... 
In and about 
houses, gardens, 
back yards, old 
flower pots, or 
tins, vessels, 
tubs, cisterns, 
barrels, gutters, 
drains. 
"Home bred " 
Resembles Cu- 
lex. 
Puddle breed- 
ing -shallow, 
small pools, in 
rock or soil, al- 
so at margins 
of lakes and 
rivers, quiet 
bays, ponds, in 
rice fields and 
water cover- 
ing submerged 
grass. 
Less "home 
bred." 
Bites.... 
By day or night 
- at twilight. 
Females only. 
Often bites by 
day. Females 
only. 
Nocturnal chief- 
ly. Females 
only. 
Wings... 
Rarely spotted.. 
Never spotted . 
Usually spotted. 
There are a few 
exceptions. 
Larval 
motility. 
Larva; float with 
heads down- 
ward. When dis- 
turbed wriggle 
to bottom of 
vessel. 
Resemble Culex. 
Float at surface 
of water like 
sticks and have 
a backward, 
skating motion. 
Resting 
posture 
"Hunch-back- 
ed." Axis of 
head and pro- 
boscis forms an 
obtuse angle 
with body. 
Resembles Cu- 
lex. 
Axis of head, 
proboscis and 
body in same 
line. Appears 
as if standing 
on its head. 
Some excep- 
tions to this 
rule. 
Eggs.... 
Deposited in el- 
lipse -shaped 
masses, convex 
below, concave 
above (boat 
shaped). Eggs 
arranged in 
rows, perpendic- 
ular and adher- 
ent, have one 
pointed end. 
Color dirty 
white. 200 to 
400 in a batch. 
Eggs are more 
oval and are 
not deposited 
in rafts or 
masses. Float 
singly upon 
their sides, or 
sink, hatching 
submerged. 
Deposited in 
masses of 40 to 
100 eggs, not 
adherent, each 
egg floating on 
its side, and 
regularly ellip- 
tic in outline, 
at middle of 
each side ap- 
pears a clasp- 
ing wrinkled 
membrane. 
Dark in color. 
Singing 
tone 
High pitched.... 
Resembles Cu- 
lex. 
Low pitched. 
Bodies .. 
Dull gray in col- 
or. 
Body and legs 
covered with 
black scales 
and white 
markings in 
spots or lines. 
S. Fasciata has 
transverse stri- 
ations on ven- 
tral aspect of 
body. 
Dark gray or 
brown. 
Heteropagus 
Heterodelphus 
Heterodymus 
Heterotypus 
Heteromorphus 
Genus I, 
Species 1. Hetero- 
typus. 
Species 2. Heteralius. Epicomus 
Species 1. Polygna- 
thus. 
Epignathus 
Hypognathus 
Paragnathus 
Augnathus 
Genus II, 
Species 2. Polyme- 
lus. 
Pygomelus 
Gastromelus 
Notomelus 
Cephalomelus 
Melomelus 
Dermocyma 
Endocyma 
Genus III, ! Endocyma 
MORBILLI.-See Measles. 
MORPHEA.-Circumscribed scleroderma; Ad- 
dison's keloid; the most common form of sclero- 
derma, usually occurring in young female adults. 
Its usual seats are about the breasts and the face 
and neck, and often it follows the course of the 
nerve distribution. It occurs in the form of 
patches-rounded, ovoid, or irregular in outline; 
small or large, soft or firm, smooth or shining, pale 
yellowish or brownish in color. The lesions are, as 
a rule, asymmetric. The course of the disease is 
chronic; it may also manifest itself in the form of 
atrophic, pit-like depressions in the skin, and as 
lines, streaks, and telangiectases. 
MORPHIN.-C17H19NO3. The name of the prin- 
cipal alkaloid of opium, to which the properties of 
that drug are chiefly due. It is an anodyne, 
hypnotic, and narcotic. One-fourth of a grain 
corresponds in activity with 1 grain of opium of 
average strength. See Opium. 
Preparations.-M. Acetas, soluble in water. 
Dose, 1/8 to 1/2 grain. M. Hydrochlorid occurs 
in silky crystals, soluble in water. Dose, 1/8 to 
1/2 grain. M., Pulv., Comp., Tully's powder, con- 
tains morphin sulphate 1 1/2, camphor, 32, lico- 
rice 33, and calcium carbonate, 33 1/2 parts. 
Dose, 5 to 15 grains. M. Sulphas, acicular crystals, 
soluble in hot water. Dose, 1/8 to 1/2 grain. 
MORRHUjE OLEUM.-See Cod-liver Oil. 
MORTALITY.-See Death-rate; Life (Expec- 
tation). 
MORTON'S DISEASE.-See Metatarsalgia. 
MORVAN'S DISEASE (Analgic Panaritium).- 
A disease characterized by disorders of sensations 
of pain, temperature and touch, and painless felons. 
Probably this disease is identical with syringomy- 
elia in most instances. In some cases it is leprosy. 
MOSCHUS.-See Musk. 
MOSQUITOS.-There are three varieties which 
Order III.-Triple Monsters. MOSQUITOS 
MOTOR POINTS 
Destruction.-The most rational method of pro- 
cedure is to aim at the extermination of these 
insects by destroying all larvae through drainage, 
ditching and leveling of their breeding places and 
especially by covering these places with kero- 
sene. The adult insects may be killed by disin- 
Another preparation is: 
1$. Oil of lavender, 
Alcohol, 
Castor oil. 
equal parts. 
Mix and apply on face and hands and sprinkle 
a few drops on a towel hung at the head of the bed. 
A H. Ebeiih k 7.o». 
Metamorphosis of Mosquitos. 
1, 2, 3, 4 and 5. Eggs, larva, pupa and heads of male and female Culex; 6, 7, 8, 
9 and 10, eggs, larva, pupa and heads of male and female Anopheles; 11, 12, 13, 
14, and 15, eggs, larva, pupa and heads of male and female Stegomyia.-(Stitt.) 
fection (especially with sulphurous acid) of rooms 
and clothing, etc., in which they lurk. See Dis- 
infection. 
To Keep Mosquitos Away.-Howard recommends 
the following to keep mosquitos from one while 
asleep: 
For Mosquito Bites.-Apply plain soap to the 
bitten places; other remedies used are: alcohol, 
ammonia, bichlorid of mercury, calcium chlorid, 
glycerin, indigo, ichthyol, potassium hydroxid (10 
percent solution), potassium permanganate, phenol, 
naphthalin, salicylic acid. 
Resting Positions of Anopheles and Culex Insects.-(Stitt.) 
Anopheles. 
CULEX. 
J$. Oil of citronella, 
Spirit of camphor, 
each 5 i 
See Filariaris, Malarial Fevers, Yellow 
Fever. 
MOTOR POINTS.-The points on the surface of 
the body where the various branches of the motor 
nerves supplying the muscles may be affected by 
electricity. See Electricity, Degeneration 
(Reaction), Muscles, etc. The accompanying 
illustrations show the principal motor points: 
Oil of cedar, 5ss. 
Mix and apply a few drops on pillow and on a 
towel near the head of the bed. 
Mosquitos do not like the smell of: Spirit of 
camphor, oil of peppermint, oil of pennyroyal, oil 
of lavender, oil of hedeoma, oil of erigeron, cade oil. MOTOR POINTS 
MOTOR POINTS 
Deltoid- - 
eus (pos- 
terior 
portion). 
Triceps (cap. 
long.). 
(D el t. 
(ant. 
I por.). 
Triceps (cap. 1 
long.). j 
M u s - 
culo- 
cuta- 
neous. 
Triceps (cap. 
extern.). 
Triceps (cap. 
intern.). 
-Biceps. 
Ulnar. < 
B ranch- 
ialis 
ant. 
Musculospiral. 
Brachialis ant. 
Median. 
Supinator long. 
Ext. radialis long. 
Ext. rad. brevis. 
Supinator longus. 
Ext. digit, com- 
munis. 
Flexor carpi 
ulnaris. 
Flex. dig. com. 
prof. 
Pronator teres. 
Ext. carpi al- 
naris. 
Supinator 
brevis. 
Flex, carpi rad. 
Extensor indicis. 
Ext. oss. metac. 
poll. 
Ext. prim, in- 
tern. poll. 
Ex, min. digit. 
Ex. indicis. 
Flex. dig. (II et 
III) subl. 
_ Flex, digit, subl. 
Ext. sec. in- 
tern. poll. 
Flex. dig. (ind. 
et min.) subl. 
Flex, longus poll. 
Median. 
Abduct, min. 
digit. 
Ulnar. 
Abduct, poll. 
Interossei dor- 
sal. (I and II). 
Inteross. dor- 
sal. (Ill and 
IV). 
Palmaris brevis. 
Abduc. dig. min. 
Flexor dig. min. 
Oppo. dig. min. 
Opponens pollicis. 
Flex, brevis poll. 
Adduc. brev. poll. 
Lumbricales. < 
Motor Points of Dorsal Aspect of Left Arm. 
Motor Points of Palmar Aspect of Left Arm. 
Gluteus maxi- 
inus. 
Sciatic. 
Biceps I 
fem < 
oris. I 
(cap. long.). 
Adductor magnus. 
Semitendinosus. 
Semimembranosus. 
Peroneal. 
(cap. brev.). 
Tibialis anticus 
Ext. digit, long. 
Gastrocnemius. 
Peroneus long. 
Peroneal. 
Post, tibial. 
Soleus. 
Gastrocnemius 1 
(cap. ext.). J 
Gastrocnemius 
(cap. int.). . 
Peroneus brevis 
Extensor hal- 
lucis longus. 
Flex, hallucis 
long. 
[Soleus. 
Soleus. 
Flexor long, hallucis. 
Flexor digit, 
comm. long. 
Ext. digit, brev. 
Tibial. 
Interossei 1 
dorsal es. J 
Abductor 
min. digit. 
Motor Points of Outer Aspect of Left leg. 
Motor Points of Posterior Aspect of Left Thigh and 
Leg. MOUNTAIN SICKNESS 
MUMPS 
MOUNTAIN SICKNESS.-A condition resulting 
from excessive exertion at high altitudes charac- 
terized by rapid pulse, dyspnea, epistaxis, slight 
rise of temperature and intense fatigue on exertion. 
MOUNTING.-See Pathologic Technic. 
MOUTH, Diseases.-See Stomatitis. 
offensive and virulent discharge, which is highly 
contagious. They appear as areas of congestion, 
swelling, and abrasion of the epidermis upon the 
lips, palate, gum, tongue, cheeks, vagina, vulva, 
scrotum, anus, and under the prepuce, and are 
often accompanied by some fissuring and ulcer- 
ation of the adjacent parts. 
The treatment requires scrupulous 
attention to cleanliness of the affect- 
ed region, applications of solid silver 
nitrate or copper sulphate, and frequent 
dusting with calomel powder. They 
may be touched with blue stone every 
day, at the same time employing an 
astringent mouth-wash. If the areas 
proliferate, they should be excised or 
burned. Growing papules may be 
cauterized with chromic acid (1 : 5), or 
nitric or carbolic acids may be used as 
caustics. A solution of zinc chlorid, 
10 grains to the ounce, makes a good 
astringent dressing for after-treatment. 
General treatment must be carried out 
at the same time. See Syphilis. 
A mouth-wash: 
1$. Boroglycerid, 5 ss 
Water, 3 viij. 
Use as a mouth-wash several times 
daily. 
MULTIPLE IMPREGNATION.-See Pregnancy 
(Multiple). 
MULTIPLE NEURITIS.-See Neuritis (Mul- 
tiple) . 
MULTIPLE SEROSITIS.-An extensive inflam- 
mation of serous membrane with primary seat in 
the pericardium, peritoneum or pleura, character- 
ized by ascites and sometimes edema of the ex- 
tremities. It is probably due to an organism of low 
virulence. The pathology and symptoms vary with 
the seat of invasion. If perihepatitis is primary, 
Glisson's capsule has the appearance of icing. 
Associated with the ascites may be found 
pleurisy and pericarditis. The affection develops 
slowly and insidiously. The patient gradually 
loses strength and death ultimately ensues from 
exhaustion. Treatment is symptomatic. 
MUMPS (Epidemic Parotitis).-An acute con- 
tagious disease, manifested locally by swelling and 
inflammation of the parotid and, rarely, of the 
other salivary glands. 
Etiology.-While probably of microbic origin, 
the specific organism has not been established. 
Mumps is highly contagious, and is usually 
communicated by the breath or exhalations, but 
may be carried by a third person or by fomites. 
Those between the ages of 10 and 14 are the most 
susceptible. Sporadic cases are sometimes ob- 
served. It is most likely to be communicated 
during the beginning of the attack, but possibly 
while the febrile symptoms remain. One attack 
usually gives immunity, but if only one of the 
parotids has been affected during the first attack, 
the other may be involved subsequently. 
Pathology.-Parotitis begins as a catarrhal in- 
Ascending fron- 
tal and parie- 
tal convolutions 
3d frontal convo- 
lution and in- 
sula (center of 
x speech). 
Temporalis. 
f Facial (upper 
[ branch). 
Facial (trunk). 
Post, auricular. 
{Facial (middle 
branch; lower 
branch). 
Splenius. 
Sternomastoideus. 
Spinal accessory. 
f Levator anguli 
( scapulae. 
Trapezius. 
f Dorsalis scapulae 
( (rhomboids). 
Circumflex. 
Long thoracic 
(serratus mag- 
(nus). 
Frontalis. 
Facial (upper). 
Corrugator super- 
cilii, 
Orbicularis palp. 
Nasal muscles. { 
Zygomatici. 
Orbicularis oris. | 
Facial (middle). 
Masseter, 
Levator menti. 
Quadratus " 
Triangularis " 
Hypoglossus. 
Facial (lower). 
Hyoid muscles. 
Ext. anterior) 
thoracic (pec- 1 
taralis prior). J 
Omohyoideus. 
Phrenic, . 
5 th and 6 th 
cervical (del- 
toid, biceps, 
brachialis, su- 
pin, longus). 
Brachial Plexus. 
Motor Points of Face and Neck. 
MUCOUS PATCHES.-These are papules de- 
prived of epithelium, a frequent lesion of acquired 
secondary and of inherited syphilis. They are 
associated with papular eruptions in early second- 
Crural. 
Tensor vag. 
femoris. 
Obturator, 
Pectineus. 
Sartorius. 
/ Quadriceps 
I (common point). 
Adductor magnus, 
Adductor longus. 
Cruralis. 
. Rectus femoris. 
Vastus extern. 
Vastus intern. 
Motor Points of Anterior Aspect of Left Thigh. 
ary syphilis. They are situated usually on mucous 
membranes, or on thin and moist skin, are gray in 
color, are circular or oval, moist, and excrete an MUMPS 
MURMURS, CARDIAC 
flammation of the ducts, involving later the peri- 
glandular connective tissue. The inflammation is 
seldom of such a nature as to cause suppuration. 
Symptoms.-The period of incubation is 10 to 
20 days; about 14 days, usually. The invasion is 
marked by languor and fever (101° to 103° F.), 
with perhaps headache and vomiting. The patient 
complains of pain at the angle of the jaw, which is 
greatly increased on swallowing an acid, such as 
vinegar. With these symptoms is noticed a 
swelling of the parotid gland on one side, the one 
on the opposite side usually soon becoming also 
involved. Occasionally but one of the glands is 
affected, and in other cases both may show the 
swelling at the same time. The swelling increases 
gradually until the third to sixth day, and pro- 
duces marked disfigurement, filling the depression 
beneath the ear and extending to the cheek and 
neck. The most prominent point is just below 
the lobe of the ear, causing it to be pressed out- 
ward. The salivary glands are usually also in- 
volved, and the mouth, as a rule, is dry, although 
in some cases there is marked salivation. When 
the swelling has reached its height, the pressure 
on the adjacent tissues causes a disagreeable feeling 
of tension; chewing, swallowing, and even speaking 
are painful and difficult. Ringing in the ears and 
earache are quite common. As a rule, the patient 
is not seriously ill, but in some cases the fever is 
high, and there may be nervous symptoms, such 
as headache or delirium. 
The duration of the attack is about a week, after 
which the swelling subsides, and by the tenth or 
twelfth day entirely disappears. 
Complications and Sequels.-Mumps usually 
runs a mild course, without any serious symptoms, 
but occasionally complications arise which add 
greatly to the severity of the disease. The most 
common complications are orchitis in the male, 
and, much less frequently, mastitis, ovaritis, or 
vulvovaginitis in the female. These inflamma- 
tions usually occur in those who have reached 
puberty, seldom being seen in children, and usu- 
ally do not appear until the swelling in the glands 
of the neck has subsided. These complications 
lengthen the course of the attack and increase the 
constitutional symptoms, but in most cases 
recovery without serious trouble occurs. 
Among the less common complications and 
sequels are otitis media and deafness, meningitis, 
arthritis, and albuminuria. 
Prognosis.-In the great proportion of cases 
mumps is a mild disease, recovery taking place in a 
few days. 
Diagnosis.-Parotitis is most likely to be con- 
founded with acute swelling of the cervical lymph- 
glands. In a parotid swelling the lobe of the ear 
is near the center of the enlargement, while that of 
a lymph-node is below the ear and behind the jaw, 
never extending upon the face. The throat 
symptoms in acute tonsillitis, diphtheria, or scarlet 
fever would prevent the swollen neck in these dis- 
eases from being mistaken for mumps. 
Treatment.-Cases of mumps occurring in 
schools or institutions and in private practice, 
when there are susceptible persons in the family, 
should be quarantined for 3 weeks. The patient 
should be confined to one room, and when the 
symptoms are at all severe, should be in bed dur- 
ing the disease, as the danger of complications 
is much increased when the patient is allowed to 
run about. The diet should be restricted to milk 
and light broths. The bowels should be acted 
upon by small doses of calomel (1/12 to 1/6 grain 
every 2 hours), after which the following'mixture 
may be given: 
1$. Antimony and potassium 
tartrate, gr. j 
Magnesium sulphate, 3 iv. 
Spirit of nitrous ether, 3 iij 
Syrup, 3 j 
Water, q. s. 3 iv. 
A teaspoonful every 3 or 4 hours. 
For the pain, restlessness, or nervous symptoms, 
1 to 3 grains of phenacetin should be given every 
3 or 4 hours. The nose and mouth should be 
sprayed and washed 3 or 4 times a day with a weak 
Dobell's solution or with any alkaline mouth- 
wash. Ichthyol ointment (10 percent) or bella- 
donna ointment should be applied to the gland if it 
is painful, and it should be supported by a bandage 
and absorbent cotton. For the anemia which 
quite often follows an attack of mumps, there 
should be given iron, codliver oil, etc. For the 
treatment of orchitis, see Testicle. 
MURMURS, CARDIAC.-Any one of those ad- 
ventitious sounds produced by the abnormal pas- 
sage of blood through the cavities and orifices 
of the heart or by perverted cardiac action. The 
names given to these murmurs correspond with the 
period of the cardiac cycle in which they occur. 
A murmur that occurs in the period of auricular 
systole is termed presystolic or auricular sys- 
tolic; one that occurs in the period of ventricular 
systole, systolic; one that occurs during the 
diastole of the ventricles, diastolic; and should 
the murmur immediately follow the first or second 
sound, postsystolic or postdiastolic respectively. 
In relation to their seat of generation cardiac 
murmurs are designated mitral, aortic, tricuspid, 
and pulmonary. All murmurs should be timed 
by the carotid pulse, not by their relation to the 
apex-beat. Murmurs are most frequently caused 
by some change in one of the cardiac valves or 
orifices, allowing of a reflux of the blood or 
obstructing its onward progress. See Heart- 
disease (Organic). MUSC7E VOLITANTES 
MUSCLE VOLITANTES 
TABLE OF ORGANIC ENDOCARDIAL MURMURS. 
Name, 
in Order of 
Frequency. 
Time 
Site t 
of Maximum ~ ^ine of 
Intensity. Conduction. 
Direct 
or In- 
direct. 
Basic 
or Lesion. 
Apical. 
Quality. 
Mitral regurgi- 
tant. 
Systolic... 
Center of mitral 
area, above and 
to left of apex. 
At sixth rib oppo- 
site apex, a line 
drawn from the 
anterior fold of 
axilla to lower an- 
gle of left scapula. 
Indirect 
mitral. 
Apical. 
Mitral insuffi- 
ciency or in- 
competence 
Variable; usually 
soft, blowing, bel- 
lows; may be dis- 
tinctly musical. 
Aortic obstruc- 
tive. 
Systolic... 
Midsternum o r 
to right of it, 
opposite third 
rib or second 
interspace. 
Toward top of ster- 
num, and along 
aorta and its 
large branches. 
Direct 
aortic. 
Basic.. . 
Aortic obstruc- 
tion or con- 
striction. 
Usually loud and 
harsh. Harsh- 
ness is one of its 
dist inguishing 
characteristics. 
Aortic regurgi- 
tant. 
Diastolic... 
Midsternum op- 
posite upper 
border of carti- 
lage of third rib. 
Down sternum to 
ensiform c a r t i- 
lage. 
Indirect 
aortic. 
Basic... 
Aortic insuffi- 
ciency or in- 
competence. 
Soft, blowing, 
sometimes rough, 
frequently m u s i- 
cal. It has the 
greatest area of 
diffusion of all the 
cardiac murmurs. 
Mitral obstruc- 
tive. 
Presysto- 
lic. 
Over mitral area 
around the apex. 
Usually not trans- 
mitted. 
Direct 
mitral. 
Apical.. 
Mitral obstruc- 
tion or con- 
striction. 
Generally 1 o w- 
pitched, rough, 
churning, grind- 
ing, or blubber- 
ing. Subject to 
great variation of 
pitch and quality. 
Tricuspid re- 
gurgitant. 
Systolic... 
Midsternum just 
above the ensi- 
form cartilage. 
Toward the epi- 
gastrium. 
Indirect 
tricus- 
pid. 
Apical. 
Tricuspid in- 
sufficiency or 
incompe- 
tence. 
L o w-pitched, s u- 
perficial, blowing, 
soft, faint. 
Tricuspid ob- 
structive- 
Presysto- 
lic. 
Midsternum op- 
posite the car- 
tilage of fourth 
rib. 
Not transmitted... 
Dir e c t 
tricus- 
pid. 
Apical.. 
Tricuspid ob- 
struction or 
constriction. 
Undetermined. 
Pulmonary ob- 
structive. 
Systolic... 
Second interspace 
to the left of 
sternum or at 
the level of 
third rib. 
Upward a short 
distance and to 
left of sternum, 
stopping ab- 
ruptly. 
Dir e c t 
pul- 
m o n- 
ary. 
Basic... 
Pulmonary ob- 
struction or 
constriction. 
Often harsh and 
audible over the 
whole precordia; 
may be very 
faint; at times 
bellows. 
Pulmonary re- 
gurgitant. 
Diastolic . 
Second left inter- 
space. 
Down left edge of 
sternum to ensi- 
form cartilage. 
Indirect 
pul- 
m o n - 
ary. 
Basic... 
Pulmonary in- 
sufficiency or 
incompe- 
tence. 
Soft and blowing. 
MUSC7E VOLITANTES.-Strings of nucleated 
rings or dots which float before the eye, and in 
some conditions, such as high myopia, are so 
numerous that they cannot be ignored, and cause 
considerable disturbance of vision. The origin 
of muscse is not exactly understood. Examina- 
tion of the muscae is of interest, and they can be 
best studied by lying on the back and looking at a 
bright cloud in the sky. By what is called ocular 
ballottement-turning the eye downward and 
arresting the movement very sharply and sud- 
denly-one may get a rebound of muscse from the 
bottom of the chamber up to the line of visual per- 
ception. While probably of no pathologic import, 
many patients drift from one oculist to another 
in the hope of relief. In such a case any existing 
ametropia or muscular imbalance should be cor- 
rected, and strict hygiene of the eyes advised. 
Very often these patients are sufferers from exces- 
sive uric acid formation, and are much relieved 
by a continued course of salines, such as phos- 
phate of sodium or other anti uric-acid remedies. 
The diet should be carefully regulated and out- 
door exercise insisted upon. MUSCLES 
MUSCLES 
MUSCLES, TABLE OF PRINCIPAL. 
Name. 
Origin. 
Insertion. 
Innervation. 
Function. 
Abductor hallucis.... 
Outer head of os calcis, 
plantar fascia, intermus- 
cular septum; inner head, 
internal annular liga- 
ment, and tendon of 
tibialis posticus. 
Inner portion of lower 
surface of base of great 
toe and inner side of 
internal sesamoid 
bone. 
Internal plantar divi- 
sion of posterior 
tibial nerve. 
Flexes and abducts first 
phalanx of great toe. 
Abductor longus pol- 
licis. 
See Extensor ossis meta- 
carpi pollicis. 
Abductor minimi 
digiti manus. 
Pisiform bone 
First phalanx of the 
little finger. 
Ulnar 
Abducts little finger. 
Abductor minimi 
digiti pedis. 
Outer tuberosity of the os 
calcis and plantar fascia. 
First phalanx of the 
little toe. 
External plantar 
Abduets little toe. 
Abductor ossis meta- 
tarsi quinti. 
Outer tubercle of calca- 
neum. 
Tuberosity of base of 
5th metatarsal bone. 
External plantar 
Abducts little toe. 
Abductor p o 11 i c i s 
manus. 
Trapezium, scaphoid, an- 
nular ligament, palmar 
fascia. 
First phalanx of thumb. 
Median 
Abducts and flexes first 
phalanx of thumb. 
Abductor p o 11 i c i s 
pedis. 
Inner tuberosity of the os 
calcis. 
First phalanx of great 
toe. 
Internal plantar 
Abducts great toe. 
Accelerator urinae ... 
Central tendon of peri- 
neum and median raphe. 
Bulb, spongy and cav- 
ernous parts of penis. 
Perineal. 
Ejects urine. 
Adductor brevis 
Ramus of pubes 
Upper part of the linea 
aspera of femur. 
Obturator 
Adducts, rotates exter- 
nally, and flexes thigh. 
Adductor hallucis.... 
Tarsal ends of the three 
middle metatarsal bones. 
Base of the first phalanx 
of great toe. 
External plantar 
Adducts great toe. 
Adductor longus 
Front of pubes 
Middle of linea aspera 
of femur. 
Obturator 
Adducts, rotates out- 
ward, and flexes thigh 
Adductor magnus.... 
Rami of pubes and is- 
chium. 
All of the linea aspera of 
femur. 
Obturator and great 
sciatic. 
Adducts thigh and ro- 
tates it outward. 
Adductor minimus... 
A name given to the upper 
portion of the adductor 
magnus. 
Adductor pollicis.... 
Third metacarpal 
First phalanx of thumb. 
Ulnar 
Draws thumb to median 
line. 
Anconeus 
Back of external condyle 
of humerus. 
Olecranon process and 
shaft of ulna. 
Musculospiral 
Extends forearm. 
Attollens aurem 
Occipitofrontalis aponeu- 
rosis. 
Pinna 
Temporal branch of 
facial. 
Elevates pinna. 
Attrahens aurem.... 
Lateral cranial aponeu- 
rosis. 
Helix 
Facial 
Advances pinna. 
Azygos uvute 
Posterior nasal spine of 
palate bone. 
Uvula 
Facial through sphe- 
nopalatine ganglion. 
Raises uvula. 
Biceps 
1. Long-Glenoid cavity. 
2. Short-Coracoid pro- 
cess. 
Tuberosity of radius.... 
Musculocutaneous ... 
Flexes and supinates 
forearm. 
Biceps femoris 
1. Ischial tuberosity. 2. 
Linea aspera. 
Head of fibula and outer 
tuberosity of head of 
fibula. 
Great sciatic and ex- 
ternal popliteal. 
Flexes and rotates leg 
outward. 
Biventer cervicis.... 
Transverse processes, 2-4 
upper dorsal vertebrae. 
Superior curved line of 
occipital bone. 
(Portion of complexus.) 
Retracts and rotates 
head. 
Brachialis anticus... 
Lower half of the shaft 
of humerus. 
Coronoid process of 
ulna. 
Musculocut a n e o u s, 
musculospiral. 
Flexes forearm. 
Brachioradialis 
See Supinator longus. MUSCLES 
MUSCLES, TABLE OF PRINCIPAL. 
MUSCLES 
Name. 
Origin. 
Insertion. 
Innervation. 
Function. 
Buccinator 
Alveolar process of max- 
illary bones and pterygo- 
maxillary ligament. 
Orbicularis oris 
Facial, buccal branch. 
Compresses cheeks, re- 
tracts angle of mouth. 
Bulbocavernous 
See Accelerator urince. 
Cervicalis ascendens.. 
Angles of five upper ribs.. 
Transverse processes of 
4th, 5th, and 6th cer- 
vical vertebrae. 
Branches of cervical.. 
Keeps head erect. 
Ciliary 
Longitudinal portion 
(Brucke's m.), junction 
of cornea and sclera; cir- 
cular portion (Muller's 
m.), fibers form a circle. 
Outer layers of choroid.. 
Ciliary 
The muscle of visua 
accommodation. 
Coccygeus 
Ischial spine 
Coccyx, sacrum, and 
sacrococcygeal 1 i g a- 
ment. 
Sacral 
Supports coccyx, and 
closes pelvic outlet. 
Complexus 
Transverse processes 7th 
cervical and 6 upper dor- 
sal, and articular proces- 
ses of 3d to 6th cervical. 
Occipital bone 
Suboccipital, great 
occipital, and bran- 
ches of cervical. 
Retracts and rotates 
head. 
Compressor narium 
Nasal aponeurosis 
Fellow muscle and 
canine fossa 
Facial 
Dilates nostril. 
Compressor narium 
minor. 
Alar cartilage 
Skin at end of nose 
Facial 
Dilates nostril. 
Compressor urethrae.. 
Ramus of pubes 
Fellow muscle 
Perineal 
Compresses membran- 
ous urethra. 
Compressor vaginae.. 
The analogue of the two 
bulbocavernosi of the 
male. 
Perineal 
Compressor of vagina. 
Constrictor of 
pharynx (inferior). 
Cricoid and thyroid carti- 
lages. 
Pharyngeal raphe 
Glossop haryngeal, 
pharyngeal plexus 
and external laryn- 
geal. 
Contracts caliber of 
pharynx. 
Constrictor of 
pharynx (middle). 
Cornua of hyoid and stylo- 
hyoid ligament. 
Pharyngeal raphe 
Glossop haryngeal 
and pharyngeal 
plexus. 
Contracts caliber of 
pharynx. 
Constrictor of 
pharynx (superior). 
Internal pterygoid plate, 
pterygomax. lig., jaw 
and side of tongue. 
Pharyngeal raphe 
Glossop haryngeal 
and pharyngeal 
plexus. 
Contracts caliber of 
pharynx. 
Coracobrachialis .... 
Coracoid process of scap- 
ula. 
Inner surface of shaft of 
humerus. 
Musculocutaneous 
Adducts and flexes arm. 
Corrugator supercilii. 
Superciliary ridge of 
frontal bone. 
Orbicularis palpebra- 
rum. 
Facial 
Draws eyebrow down- 
ward and inward. 
Cremaster 
Upper and deep surface 
of middle of Poupart's 
ligament. 
Spine and crest of pubic 
bone and fascia pro- 
pria. 
Genital branch of 
genitocrural. 
Elevates testicle. 
Crureus 
See Vastus internus. 
Deltoid 
Clavicle, acromion, and 
spine of scapula. 
Shaft of humerus 
Circumflex 
Abducts humerus. 
Depressor alse nasi... 
Incisive fossa of superior 
maxillary bone. 
Septum and ala of nose. 
Facial, buccal branch. 
Contracts nostril. 
Depressor anguli oris. 
External oblique line of 
inferior maxillary bone. 
Angle of mouth 
Facial, supramaxil- 
lary branch. 
Depresses angle of 
mouth. 
Depressor labii inferi- 
oris. 
External oblique line of 
the inferior maxillary 
bone. 
Lower lip 
Facial, supramaxil- 
lary branch. 
Depresses lip. 
Depressor urethrae... 
Ramus of ischium near 
deep transversus perinei. 
Fibers of constrictor va- 
ginae muscle. MUSCLES 
MUSCLES 
MUSCLES, TABLE OF PRINCIPAL. 
Name. 
Origin. 
1 
Insertion. 
Innervation. 
Function. 
Detrusor urinse 
Front of pubes 
Prostate (in male), va- 
gina (in female). 
Sympathetic 
Compresses bladder. 
Diaphragm 
Ensiform cart., 6 or 7 
lower ribs, ligamenta 
arcuata, bodies of lumbar 
vertebrae. 
Central tendon 
Phrenic and sympa- 
thetic. 
Respiration and expul- 
sion. 
Digastric (anterior 
belly). 
Inner surface of inferior 
maxillary bone, near 
symphysis. 
Hyoid bone 
Inferior dental 
Elevates hyoid and 
tongue. 
Digastric (posterior 
belly). 
Digastric groove of mas- 
toid process. 
Hyoid bone 
Facial 
Elevates hyoid a nd 
tongue. 
Dilator naris anteri- 
oris. 
Alar cartilage 
Border of ala of nose... 
Facial, infraorbital 
branch. 
Dilates nostril. 
Dilator naris posteri- 
oris. 
Nasal notch of superior 
maxillary bone. 
Skin at margin of nos- 
tril. 
Facial, infraorbital 
branch. 
Dilates nostril. 
Dorsal interossei, 4.. 
Sides of metacarpal bones. 
Bases of corresponding 
phalanges. 
Ulnar 
Abduct fingers from me- 
dian line. 
Dorsal interossei, 4... 
Sides of metatarsal bones. 
Base of first phalanx of 
corresponding toe. 
External plantar 
Abduct toes. 
Erector clitoridis.... 
Tuberosity of ischium 
Each side of crus of cli- 
toris. 
Erects clitoris. 
Erector penis 
Ischial tuberosity, crus 
penis, and pubic ramus. 
Tunica albuginea of cor- 
pus cavernosum. 
Perineal 
To maintain erection. 
Erector spime 
Iliac crest, back of sacrum, 
lumbar, and three lower 
dorsal spines. 
Divides into sacrolum- 
balis, longissimus dor- 
si, and spinalis dorsi. 
Lumbar nerves, pos- 
terior division. 
Extension of lumbar 
spines on pelvis. 
Extensor brevis digi- 
torum pedis. 
Os calcis, externally 
First phalanx of great 
toe and tendons of ex- 
tensor longus. 
Anterior tibial 
.. Extends toes. 
Extensor brevis hal- 
lucis. 
A name applied to that 
portion of the extensor 
brevis digitorum that 
goes to the great toe. 
Extensor brevis pol- 
licis. 
See Extensor primi inter 
nodii pollicis. 
Extensor carpi radi- 
alis brevior. 
External condyloid ridge 
of humerus. 
Base second and third 
metacarpal. 
Posterior interosseous. 
Extends wrist. 
Extensor carpi radi- 
alis longior. 
Lower J external condy- 
loid ridge of humerus. 
Base of second meta- 
carpal. 
Musculospiral 
Extends wrist. 
Extensor carpi ul- 
naris. 
1st head, external condyle 
of humerus. 2d head, 
posterior border of ulna. 
Base of fifth metacarpal. 
Posterior interosseous. 
Extends wrist. 
Extensor coccygis. .. 
Last bone of sacrum or 
first of coccyx. 
Lower part of coccyx... 
Sacral branches 
Extends coccyx. 
Extensor communis 
digitorum. 
External condyle of hu- 
merus. 
All of the second and 
third phalanges. 
Posterior interosseous. 
Extends fingers. 
Extensor indicis 
Back of ulna 
Second and third pha- 
langes of index finger. 
Posterior interosseous. 
Extends index. 
Extensor longus digi- 
torum pedis. 
Outer tuberosity of tibia 
and shaft of fibula. 
Second and third pha- 
langes of toes. 
Anterior tibial .. 
Extends toes. 
Extensor longus pol- 
licis. 
See Extensor secundi in 
ternodii pollicis. 
Extensor minimi dig- 
iti. 
External condyle of hu- 
merus. 
Second and third pha- 
langes of little finger. 
Posterior interosseous 
Extensor of little finger. MUSCLES 
MUSCLES 
MUSCLES, TABLE OF PRINCIPAL. 
Name. 
Origin. 
Insertion. 
Innervation. 
Function. 
Extensor ossis meta- 
carpi pollicis. 
Back of radius and ulna 
and interosseous mem- 
brane. 
Base of metacarpal of 
thumb and fascia. 
Posterior interosseous. 
Extends thumb. 
Extensor primi in- 
ternodii pollicis. 
Back of radius 
Base of first phalanx of 
thumb. 
Posterior interosseous. 
Extends thumb. 
Extensor proprius di- 
giti minimi. 
Lower part of ulna, or 
posterior ligament of 
wrist-joint. 
Base of first phalanx of 
little finger. 
Extensor proprius 
hallucis. 
Middle of fibula 
Base of last phalanx of 
great toe. 
Anterior tibial 
Extends great toe. 
Extensor secundi in- 
ternodii pollicis. 
Back of ulna 
Base of last phalanx of 
thumb. 
Posterior interosseous. 
Extends thumb. 
Flexor accessorius 
digitorum pedis (2 
heads). 
1. Inner; 2. Outer surface 
of os calcis. 
Tendon of flexor longus 
digitorum. 
External plantar 
Accessory flexor of toes. 
Flexor accessorius 
longus digitorum 
pedis. 
Shaft of tibia or fibula.... 
Tubercle of os calcis, 
and joins tendon of 
long flexor. 
External plantar 
Assists in flexing toes. 
Flexor brevis digito- 
rum pedis. 
Inner tuberosity of os 
calcis and plantar fascia. 
Second phalanges of the 
lesser toes. 
Internal plantar 
Flexes lesser toes. 
Flexor brevis hallucis. 
Under surface of cuboid, 
plantar ligaments, and 
external cuneiform. 
Base of first phalanx of 
great toe. 
Internal plantar 
Flexes and slightly ad- 
ducts first phalanx of 
great toe. 
Flexor brevis minimi 
digiti manus. 
Unciform bone and annu- 
lar ligament. 
First phalanx of little 
finger. 
Ulnar 
Flexes little finger. 
Flexor brevis minimi 
digiti pedis. 
Base of fifth metatarsal... 
Base of first phalanx of 
little toe. 
External plantar 
Flexes little toe. 
Flexor brevis pollicis 
manus. 
2 heads-outer; lower bor- 
der of anterior annular 
ligament; ridge of trape- 
zium; inner: os mag- 
num, and bases of first, 
second, and third meta- 
carpal bones. 
Base of first phalanx of 
thumb. 
Outer head-median, 
palmar branch. In- 
ner head-deep ul- 
nar. 
Flexes metacarpal bone 
of thumb. 
Flexor brevis pollicis 
pedis. 
See Flexor brevis hallucis. 
Flexor carpi radialis. 
Internal condyle of hu- 
merus. 
Metacarpal bone of in- 
dex finger. 
Median 
Flexes wrist. 
Flexor carpi ulnaris 
(2 heads). 
1. Internal condyle. 2. 
Olecranon and ulna. 
5th metacarpal, annular 
lig. and pisiform bone. 
Ulnar 
Flexes wrist. 
Flexor longus digi- 
torum pedis. 
Shaft of tibia 
Last phalanges of toes.. 
Posterior tibial 
Flexes phalanges and ex- 
tends ankle. 
Flexor longus hallucis 
Lower two-thirds of shaft 
of fibula. 
Last phalanx of great 
toe. 
Posterior tibial 
Flexes great toe. 
Flexor longus pollicis. 
Shaft of radius and coro- 
noid process of ulna. 
Last phalanx of thumb. 
Anterior interosseous. 
Flexes the thumb. 
Flexor profundus 
digitorum. 
Shaft of ulna 
Last phalanges by four 
tendons. 
Ulnar and anterior 
interosseous. 
Flexes the phalanges. 
Flexor sublimis digi- 
torum (3 heads). 
1. Inner condyle. 2. Co- 
ronoid process. 3. Ob- 
lique line of radius. 
Second phalanges by 
four tendons. 
Median 
Flexes second phalanges. 
Gastrocnemius 
(2 heads). 
Condyles of femur 
Os calcis by tendo 
Achillis. 
Internal popliteal.... 
Extends foot. 
Gemellus inferior.... 
Tuberosity of ischium and 
lesser sacro-sciatic notch. 
Great trochanter 
Sacral 
External rotator of 
thigh. MUSCLES 
MUSCLES 
MUSCLES, TABLE OF PRINCIPAL. 
Name. 
Origin. 
Insertion. 
Innervation. 
Function. 
Gemellus superior.... 
Ischial spine and lesser 
sacro-sciatic notch. 
Great trochanter 
Sacral 
External rotator of 
thigh. 
Geniohyoglossus 
Superior genial tubercle of 
inferior maxillary bone. 
Hyoid and inferior sur- 
face of tongue. 
Hypoglossal 
Retracts and protrudes 
tongue. 
Geniohyoid 
Inferior genial tubercle 
of inferior maxillary 
bone. 
Body of hyoid 
Hypoglossal 
Elevates and advances 
hyoid. 
Gluteus maximus.... 
Sup. curved iliac line and 
crest, sacrum, and 
coccyx. 
Fascia and femur below 
great trochanter. 
Inferior gluteal and 
sacral plexus. 
Extends, abducts, and 
rotates thigh outward. 
Gluteus medius 
Ilium between superior 
and middle curved lines. 
Oblique line of great 
trochanter. 
Superior gluteal 
Rotates, abducts, and 
advances thigh. 
Gluteus minimus 
Ilium between middle and 
inferior curved lines. 
Great trochanter 
Superior gluteal 
Rotates, abducts, and 
draws thigh forward. 
Gracilis 
Rami of pubes and 
ischium. 
Tibia, upper and inner 
part 
Obturator 
Flexes and abducts leg. 
Gubernaculum testis. 
See Cremaster. 
Hyoglossus 
Cornua of hyoid 
Side of tongue 
Hypoglossal 
Depresses side of tongue 
and retracts tongue. 
Iliacus 
Iliac fossa, crest, base of 
sacrum. 
Lesser trochanter, up- 
per part shaft femur. 
Anterior crural 
Flexes and rotates 
femur outward. 
Iliocostal 
See Sacrolumbar. 
Iliopsoas 
The iliacus and psoas con- 
sidered as one muscle. 
Infracostals, 10 
Inner surface of ribs 
Inner surface of two or 
three ribs above. 
Intercostals 
Expiration, by depress- 
ing ribs. 
Infraspinatus 
Infraspinous fossa 
Great tuberosity of 
humerus. 
Suprascapular 
Rotates humerus out- 
ward. 
Intercostals, exter- 
nal, 11. 
Outer lip of inferior costal 
border. 
Superior border of ribs 
above. 
Intercostal 
Raise ribs in inspiration 
Intercostals, inter- 
nal, 11. 
Inner lip of inferior costal 
border. 
Superior border of ribs 
below. 
Intercostal 
Depress ribs in expira- 
tion. 
Interossei of foot, 
dorsal (4). 
Adjacent surfaces of meta- 
tarsal bones. 
Bases of first phalanges. 
External plantar 
Flex first phalanges and 
extend 2d and 3d, also 
abduct 2d, 3d, and 4th 
toes. 
Interossei of foot, 
plantar (3). 
Inner lower surface of 3 
outer metatarsal bones. 
Bases of first phalanges 
of three outer toes. 
1 External plantar .... 
Abduct first phalanges 
of three outer toes. 
Interossei of hand, 
dorsal (4). 
Five metacarpal bones.... 
Sides of aponeurosis of 
extensor communis 
and adjacent parts of 
first phalanges. 
Ulnar 
Abduct index, middle, 
and ring fingers, aid in 
flexing first phalanges 
and extending second 
and third. 
Interossei of hand, 
palmar (3). 
Sides of metacarpal bones. 
Aponeurosis of extensor 
tendons, adjacent part 
of first phalanges. 
Ulnar 
Adduct index, ring, and 
little fingers, aid in flex- 
ing first phalanges and 
in extending second 
and third. 
Interspinales 
Upper surface of spines of 
vertebrae, near tip. 
Posterior part of lower 
surface of spine above. 
■ Internal divisions of 
; posterior branches of 
spinal nerves. 
Extend the vertebra 
next above. 
Intertransversales... 
Between transverse proc, 
of contiguous vertebrae. 
Spinal nerves 
Flex laterally the spinal 
column. 
Ischiocavernosus 
See Erector penis. MUSCLES 
MUSCLES 
MUSCLES, TABLE OF PRINCIPAL. 
Name. 
Origin. 
Insertion. 
Innervation. 
Function. 
Latissimus dorsi 
Spines of 6 lower dorsal 
and lumbar and sacral 
vertebrae, crest of ilium, 
and 3 or 4 lower ribs. 
Bicipital groove of 
humerus. 
Long subscapular.... 
Draws arm backward 
and downward and 
rotates it inward. 
Levator anguli oris... 
Canine fossa of superior 
maxillary bone. 
Angle of mouth 
Facial, infraorbital 
branch. 
Elevates angle of mouth. 
Levator anguli 
scapulae 
Transverse processes of 
four upper cervical ver- 
tebrae. 
Posterior border of 
scapula. 
Fifth cervical and 
cervical plexus. 
Elevates upper angle of 
scapula. 
Levator ani 
Posterior portion of body 
and ramus of pubes, pel- 
vic fascia, ischial spine. 
Rectum, coccyx, and 
fibrous raphe. 
Sacral and perineal.., 
Supports rectum and 
vagina. 
Levator labii 
inferioris. 
Incisive fossa of inferior 
maxillary bone. 
Skin of lower lip 
Facial, supramaxil- 
lary branch. 
Elevates lower lip. 
Levator labii 
superioris. 
Lower margin of orbit.... 
Upper lip 
Facial, infraorbital 
branch. 
Elevates upper lip. 
Levator labii 
superioris al®que 
nasi. 
Nasal process of superior 
maxillary bone. 
Alar cartilage and upper 
lip. 
Facial, infraorbital 
branch. 
Elevates upper lip, di- 
lates nostril. 
Levator menti 
See Levator labii inferioris. 
Levator palati 
Petrous portion of tempo- 
ral bone. 
Soft palate 
Sphenopalatine gan- 
glion (facial). 
Elevates soft palate. 
Levator palpebrae 
superioris. 
Lesser wing of sphenoid... 
Upper tarsal cartilage.. 
Third 
Lifts upper lid. 
Levatores costarum, 
12. 
Transverse processes of 
last cervical and dorsal 
vertebrae. 
Each to the rib below... 
Intercostal 
Raise ribs. 
Lingualis 
Under surface of tongue.. . 
Chorda tympani and 
hypoglossal 
Elevates middle of 
tongue. 
Longissimus dorsi.... 
Erector spinae 
Transverse process of 
lumbar and dorsal 
vertebr® and 7th to 
11th ribs. 
Branches of lumbar 
and dorsal. 
Erects spine and bends 
trunk backward. 
Longus colli- 
1. Superior oblique 
portion. 
2. Inferior oblique 
portion. 
3. Vertical portion. 
Transverse processes 3d to 
5th cervical. 
Bodies of 1st to 3d dorsal. 
Bodies of three dorsal and 
two cervical. 
Anterior tubercle of 
atlas. 
Transverse processes 
5th to 6th cervical. 
Bodies of 2d to 4th cervi- 
cal. 
Lower cervical 
Flexes cervical verte- 
br®. 
Lumbricales, 4, of 
foot. 
Tendons of flexor longus 
digitorum. 
First phalanges of the 
lesser toes. 
Internal and external 
plantar. 
Accessory flexors. 
Lumbricales, 4, of 
hand. 
Tendons of flexor profun- 
dus digitorum. 
Tendons of common ex- 
tensor. 
Median and ulnar... . 
Flex first phalanges. 
Masseter 
Zygomatic arch 
Angle and ramus of jaw. 
Inferior maxillary.... 
Muscle of mastication. 
Multifidus spinae 
Sacrum, iliac spine, artic- 
ular processes lumbar 
and cervical vertebrae, 
and transverse proc, of 
dorsal and 7th cervical. 
Lamin® and spines from 
last lumbar to second 
cervical vertebr®. 
Posterior spinal 
branches. 
Erects and rotates spinal 
column. 
Mylohyoid 
Mylohyoid ridge of infe- 
rior maxillary bone. 
Body of hyoid and 
raphe. 
Inferior dental 
Elevates and advances 
hyoid. Forms the floor 
of the mouth. 
Nasolabialis 
Nasal septum 
Upper lip. 
Obliquus capitis infe- 
rior. 
Spinous process of axis.... 
Transverse process of 
atlas. 
Suboccipital and 
great occipital. 
Rotates altas and cra- 
nium. 
Obliquus capitis su- 
perior. 
Transverse process of atlas. 
Occipital bone 
Suboccipital and 
great occipital. 
Draws head backward. MUSCLES 
MUSCLES 
MUSCLES, TABLE OF PRINCIPAL. 
Name. 
Origin. 
Insertion. 
Innervation. 
Function. 
Obliquus externus... 
Eight lower ribs 
Middle line, iliac crest, 
Poupart's ligament. 
Intercostal, iliohypo- 
gastric, ilioinguinal. 
Compresses viscera and 
flexes thorax. 
Obliquus inferior. ... 
Orbital plate of superior 
maxillary bone. 
Sclerotic 
Third cranial 
Rotates eyeball upward 
and outward. 
Obliquus internus.... 
Lumbar fascia, iliac crest, 
Poupart's ligament. 
Three lower ribs, linea 
alba, pubic crest, pec- 
tineal line. 
Intercostal, iliohypo- 
gastric, ilioinguinal. 
Compresses viscera, 
flexes thorax, and as- 
sists in expiration. 
Obliquus superior.... 
Above optic foramen, 
through pulley. 
Sclerotic 
Fourth cranial 
Rotates eyeball down- 
ward and inward. 
Obturator externus.. 
Obturator foramen and 
membrane. 
Digital fossa, base of 
great trochanter. 
Obturator 
External rotator of 
thigh. 
Obturator internus... 
Obturator foramen and 
membrane. 
Great trochanter 
Sacral 
External rotator of 
thigh. 
Occipitofrontalis 
Superior curved line of 
occiput and angular pro- 
cess of frontal. 
Aponeurosis 
Posterior auricular, 
small occipital, fa- 
cial. 
Moves scalp. Facial ex- 
pression. 
Omohyoid 
Upper border of scapula... 
Body of hyoid.. M 
Descendens and com- 
municans noni (hy- 
poglossi). 
Depresses and retracts 
hyoid. 
Opponens minimi 
digiti. 
Unciform bone 
Fifth metacarpal 
Ulnar 
Flexes little finger. 
Opponens pollicis.... 
Trapezium, anterior annu- 
lar ligament. 
Metacarpal bone of 
thumb. 
Median, palmar divi- 
sion. 
Flexes thumb. 
Orbicularis oris 
Nasal septum and canine 
fossa of inferior maxilla, 
by accessory fibers. 
Forms lips and sphinc- 
ter of mouth. 
Facial, buccal and 
sup ramaxillary 
branches. 
Closes mouth. 
Orbicularis palpe- 
brarum. 
Mesal margin of orbit 
Lateral margin of orbit. 
Facial 
Closes eyelids. 
Palatoglossus 
Soft palate 
Side and dorsum of 
tongue. 
Sphenopalatine gan- 
glion. 
Constricts the fauces. 
Palatopharyngeus .. . 
Soft palate 
Thyroid cartilage and 
pharynx. 
Sphenopalatine gan- 
glion. 
Closes posterior nares. 
Palmaris brevis 
Annular ligament and 
palmar fascia. 
Skin of palm of hand... 
Ulnar 
Corrugates skin of palm. 
Palmaris interossei . . 
Palmar surfaces second, 
fourth, and fifth meta- 
carpals. 
Bases of first phalanges 
of corresponding fin- 
gers. 
Ulnar 
Adductors of fingers. 
Palmaris longus 
Internal condyle of 
humerus. 
Annular ligament and 
palmar fascia. 
Median 
Makes tense the palmar 
fascia. 
Pectineus 
Uiopectineal line and 
pubes. 
Femur below lesser tro- 
chanter. 
Anterior crural, ob- 
turator. 
Flexes and rotates out- 
ward the thigh. 
Pectoralis major 
Clavicle, sternum, and 
costal cartilages. 
External bicipital ridge 
of humerus. 
Anterior thoracic, ex- 
ternal and internal. 
Draws arm downward 
and forward. 
Pectoralis minor 
Third, fourth, and fifth 
ribs. 
Coracoid process 
Anterior thoracic .... 
Depresses point of 
shoulder. 
Peroneus brevis 
Middle third of shaft of 
fibula, externally. 
Base of fifth metatarsal. 
Musculocutaneous ... 
Extends foot. 
Peroneus longus 
Head and shaft of fibula. . 
First metatarsal of great 
toe. 
Musculocutaneous ... 
Extends and everts foot. 
Peroneus tertius 
Lower fourth of fibula. ... 
Fifth metatarsal bone... 
Anterior tibial 
Flexes tarsus. 
Plantaris 
Outer bifurcation of linea 
aspera and posterior liga- 
ment of knee-joint. 
Os calcis by means of 
the tendo Achillis. 
Internal popliteal.... 
Extends foot. 
Plantaris interossei.. 
Shafts of 3d, 4th, and 5th 
metatarsal bones. 
Bases of first phalanges 
of corresponding toes. 
External plantar 
Adducts toes. MUSCLES 
MUSCLES 
MUSCLES, TABLE OF PRINCIPAL. 
Name. 
Origin. 
Insertion. Innervation. 
Function. 
Platysma myoides... 
Clavicle, acromion, and 
fascia. 
Inferior maxillary bone, 
angle of mouth. 
Facial and superficial 
cervical. 
Wrinkles skin and de- 
presses mouth. 
Popliteus 
External condyle of fe- 
mur. 
Shaft of tibia above ob- 
lique line. 
Internal popliteal.... 
Flexes leg. 
Pronator quadratus . 
Pronator radii teres . 
Lower fourth of ulna 
Lower i shaft of radius. 
Anterior interosseous 
Pronates hand. 
Internal condyle and coro- 
noid process. 
Outer side of shaft of 
radius. 
Median 
Pronates hand. 
Psoas magnus 
Bodies and transverse pro- 
cesses of last dorsal and 
all lumbar vertebrae. 
Lesser trochanter 
Lumbar 
Flexes and rotates thigh 
outward, and flexes 
trunk on pelvis. 
Psoas parvus 
Bodies of last dorsal and 
first lumbar vertebrae. 
Uiopectineal eminence 
and iliac fascia. 
Lumbar 
Flexes pelvis upon ab- 
domen. 
Pterygoid (external). 
Two heads: 1. external 
pterygoid plate of sphe- 
noid bone; 2. great wing. 
Neck of condyle 
Inferior maxillary.... 
Draws inferior maxil- 
lary bone forward. 
Pterygoid (internal). 
Pterygoid fossa of sphe- 
noid bone. 
Inner surface of angle 
of j^w. 
Inferior maxillary.... 
Raises and draws infe- 
rior maxilla forward. 
Pyramidalis 
Pubes 
Linea alba 
Iliohypogastric 
Tenses linea alba. 
Pyramidalis nasi.... 
Occipitofrontalis 
Compressor naris 
Facial nerve, infraor- 
bital branch. 
Depresses eyebrow. 
Pyriformis 
Front of sacrum, through 
great sciatic foramen. 
Great trochanter 
Sacral branch 
External rotator of 
thigh. 
Quadratus femoris... 
Tuberosity of the ischium 
Quadrate line of femur. 
First sacral and fifth 
lumbar. 
External rotator of thigh. 
Quadratus lumborum 
Crest of ilium, transverse 
processes of lower three 
lumbar vertebrae. 
Last rib, transverse pro- 
cesses of upper three 
lumbar vertebrae. 
Upper lumbar and 
twelfth thoracic. 
Flexes thorax laterally. 
Quadriceps extensor 
femoris. 
Includes the rectus, vastus internus and externus, and crureus muscles. Their common tendon 
contains the patella. 
Rectus abdominis.... 
Pubic crest and fibrous 
tissues in front of sym- 
physis. 
Cartilages of the fifth to 
seventh ribs. 
Intercostal, iliohypo- 
gastric, ilioinguinal. 
Compresses viscera and 
flexes thorax. 
Rectus capitis 
anticus major. 
Transverse processes 3d to 
6th cervical vertebrae. 
Basilar process 
First and second cer- 
vical. 
Flexes head and slightly 
rotates it. 
Rectus capitus anti- 
cus minor. 
Transverse process and 
lateral mass of atlas. 
Basilar process of occi- 
pital bone. 
First cervical 
Flexes head. 
Rectus capitis later- 
alis. 
Ventral cephalic surface 
of lateral mass of atlas. 
Jugular process of occi- 
pital bone. 
First cervical 
Flexes head laterally. 
Rectus capitis posti- 
cus major. 
Spine of axis 
Inferior curved line of 
occipital bone. 
Suboccipital and 
great occipital. 
Rotates head. 
Rectus capitis posti- 
cus minor. 
Dorsal arch of atlas 
Below inferior c u r v ed 
line of occipital bone. 
Suboccipital and 
great occipital. 
Draws head backward. 
Rectus externus 
Two heads, outer margin 
of optic foramen. 
Sclera 
Sixth cranial........ 
Rotates eyeball out- 
ward. 
Rectus femoris 
Anterior inferior iliac 
spine, brim acetabulum. 
Proximal border of 
patella. 
Anterior crural 
Extends leg. 
Rectus inferior 
Lower margin of optic 
foramen. 
Sclera 
Third cranial 
Rotates eyeball down- 
ward. 
Rectus internus 
Inner margin of optic 
foramen. 
Sclera 
Third cranial 
Rotates eyeball inward. 
Rectus superior 
Upper margin of optic 
foramen. 
Sclera 
Third cranial 
Rotates eyeball upward. 
Retrahens aurem.... 
Mastoid process 
Concha 
Posterior auricular. .. 
Retracts pinna. MUSCLES 
MUSCLES 
MUSCLES, TABLE OF PRINCIPAL. 
Name. 
Obigin. 
Insebtion. 
Innebvation. 
Function. 
Rhomboideus major. 
Spines of first five thor- 
acic vertebrae. 
Root of spine of scapula. 
Fifth cervical 
Elevates and retracts 
scapula. 
Rhomboideus minor. 
Spines of seventh cervical 
and first dorsal vertebrae. 
Root of spine of scapula. 
Fifth cervical 
1 Retracts and elevates 
scapula. 
Risorius 
Fascia over masseter 
Angle of mouth 
Facial, buccal branch. 
.... ... 
Draws angle laterally. 
Rotatores spinse 
Transverse processes of 
from second to twelfth 
thoracic vertebrae. 
Lamina of next vertebra 
above. 
Dorsal branches 
Rotate spinal column. 
Sacrolumbalis 
Erector spinae 
Angle of six lower ribs. 
Branches of dorsal... 
Erects spine and bends 
trunk backward. 
Sartorius 
Anterior superior spine 
of ilium. 
Upper internal portion 
of shaft of tibia. 
Anterior crural 
Flexes and crosses legs. 
Scalenus anticus 
Scalene tubercle on first 
rib. 
Transverse processes 3d 
to 6th cervical vertebrae. 
Lower cervical 
Flexes neck laterally. 
Scalenus medius 
First rib 
Transverse processes of 
six lower cervical ver- 
tebrae. 
Lower cervical 
Flexes neck laterally. 
Scalenus posticus.... 
Second rib 
Transverse processes of 
three lower cervical 
vertebrae. 
Lower cervical 
Bends neck laterally. 
Semimembranosus... 
Tuberosity of ischium 
Inner tuberosity of tibia 
Great sciatic 
Flexes leg and rotates it 
inward. 
Semispinalis coli 
Transverse processes four 
upper dorsal and articu- 
lar processes four lower 
cervical vertebrae. 
Spines of second to fifth 
cervical vertebrae. 
Cervical branches.... 
Erects spinal column. 
Semispinalis dorsi.... 
Transverse processes 6th 
to 10th dorsal vertebrae. 
Spines last two cervical 
and first four thoracic. 
Branches of dorsal. .. 
Erects spinal column. 
Semitendinosus 
Tuberosity of ischium 
Upper and inner surface 
of tibia. 
Great sciatic 
Flexes leg on thigh. 
Serratus magnus 
Eight upper ribs 
Inner margin of dorsal 
border of scapula. 
Posterior thoracic.... 
Elevates ribs in inspira- 
tion. 
Serratus posticus in- 
ferior. 
Spines of last two thoracic 
and first three lumbar. 
Four lower ribs 
Tenth and eleventh 
intercostal. 
Depresses ribs in ex- 
piration. 
Serratus posticus su- 
perior. 
Spines of seventh cervical 
and first two thoracic 
vertebrae. 
Second, third, fourth, 
and fifth ribs. 
Second and third in- 
tercostal. 
Raises ribs in inspira- 
tion. 
Soleus 
Shaft of fibula, oblique 
line of tibia. 
Os calcis by tendo 
Achillis. 
Internal popliteal and 
posterior tibial. 
Extends foot. 
Sphincter ani, exter- 
nal. 
Tip of coccyx 
Tendinous center of 
perineum. 
Perineal, pudic, and 
fourth sacral. 
Closes anus. 
Sphincter ani, inter- 
nal. 
A thickening of the circu- 
lar fibers of the intestine 
one inch above the anus. 
Hemorrhoidal nerves. 
Constricts rectum. 
Sphincter vaginae.... 
Central tendon of peri- 
neum. 
Corpora cavernosa of 
clitoris. 
Homologue of accelera 
x>r urinae in male. 
Sphincter vesicae in- 
tern us 
Near the urethral orifice of 
the bladder. 
Vesical nerves 
Constricts internal ori- 
fice of urethra. 
Spinalis cervicis (nor- 
mal, but inconstant). 
Spines 5th, 6th, and 7th 
cervical and first two 
thoracic vertebrae. 
Spine of axis, some- 
times spines of 3d and 
4th cervical vertebrae. 
Spinilis colli 
Spines of fifth and sixth 
cervical vertebrae. 
Spine of axis, or third 
and fourth cervical 
spines. 
Cervical branches.... 
Steadies neck. 
Spinalis dorsi 
Last two thoracic and first 
two lumbar spines. 
Remaining thoracic 
spines. 
Dorsal branches 
Erects spinal column. MUSCLES 
MUSCLES 
MUSCLES, TABLE OF PRINCIPAL 
Name. 
Splenius capitis 
Origin. 
Lower two-thirds ligamen- 
tum nuch®, spines of 
seventh cervical and first 
two thoracic vertebrae. 
Insertion. 
Outer third of middle 
oblique line of occiput 
and outer surface of 
mastoid process. 
Innervation. 
Middle cervical, pos- 
terior branches. 
Function. 
Extends head and neck 
and rotates and flexes 
laterally. 
Splenius colli. 
Spines of third to sixth 
thoracic vertebrae. 
Dorsal tubercles of 
transverse processes of 
upper three or four cer- 
vical vertebrae. 
Posterior divisions of 
lower cervical. 
Extends, flexes lateral- 
ly, and rotates neck. 
Stapedius 
Sternocleidomas- 
toid. 
Interior of pyramid 
Neck of stapes 
Facial 
Depresses base of stapes. 
Two heads, sternum and 
clavicle. 
Mastoid process and 
outer half of superior 
oblique line of occiput. 
Spinal accessory and 
cervical plexus. 
Depresses and rotates 
head. 
Sternohyoid 
Sternum and clavicle 
Hyoid bone 
Descending and com- 
municating branches 
of the hypoglossal. 
Depresses hyoid. 
Sternothyroid 
Sternum and cartilage of 
first rib. 
Side of thyroid carti- 
lage. 
Descendens and com- 
municans hypoglossi. 
Depresses larynx. 
Styloglossus 
Styloid process 
Side of tongue 
Hypoglossal 
Elevates and retracts 
tongue. 
Stylohyoid 
Styloid process 
Body of hyoid 
Facial 
Draws hyoid upward 
and backward. 
Stylopharyngeus .... 
Styloid process 
Thyroid cartilage 
Glossopha r y n g e a 1, 
and pharyngeal plex- 
us 
Elevates pharynx. 
Subanconeus 
Humerus above olecranon 
fossa. 
Posterior ligament of 
elbow. 
Musculospiral. 
Tensor of ligament. 
Subclavius 
Cartilage of first rib 
Inferior surface of clav- 
icle. 
Fifth and sixth cer- 
vical. 
Draws clavicle down- 
ward. 
Subcrureus 
Anterior distal part of 
femur. 
Synovial sac behind 
patella. 
Anterior crural 
Draws sac up. 
Subscapularis 
Subscapular fossa 
Humerus, lesser tuber- 
osity, and shaft. 
Subscapular 
Chief internal rotator of 
humerus. 
Supinator longus 
External condyloid ridge 
of humerus. 
Styloid process of ra- 
dius. 
Musculospiral 
Flexes forearm. 
Supinator radii 
brevis. 
External condyle of hu- 
merus, oblique line of 
ulna. 
Neck of radius and its 
bicipital tuberosity. 
Posterior interosse- 
ous. 
Supinates hand. 
Supraspinales 
Lie on spinous processes in cervical region. 
Supraspinatus 
Supraspinous fossa 
Great tuberosity of hu- 
merus. 
Suprascapular 
Supports shoulder-joint, 
raises arm. 
Temporal 
Temporal fossa and fascia. 
Coronoid process of 
mandible. 
Inferior maxillary.... 
Closes mandible. 
Tensor palati 
Scaphoid fossa and alar 
spine of sphenoid. 
About hamular process 
into soft palate. 
Otic ganglion 
Renders palate tense. 
Tensor tarsi 
Crest of lacrimal bone 
Tarsal cartilages 
Facial, infraorbital 
branch. 
Compresses puncta and 
lacrimal sac. 
Tensor tympani 
Temporal bone, Eusta- 
chian tube and canal, 
sphenoid bone. 
Handle of malleus 
Otic ganglion 
Renders tense the mem- 
brana tympani. 
Tensor vaginae fem- 
oris. 
Iliac crest and anterior 
superior spinous process. 
Fascia lata 
Superior gluteal 
Tensor of fascia. 
Teres major 
Inferior angle of scapula.. 
Internal bicipital ridge 
of humerus. 
Subscapular 
Draws arm downward 
and backward. MUSCLES 
MUSCLES 
MUSCLES, TABLE OF PRINCIPAL. 
Name. 
Origin. 
Insertion. 
Innervation. 
Function. 
Teres minor 
Axillary border of scap- 
ula 
Great tuberosity of hu- 
merus. 
Circumflex 
Rotates humerus out- 
ward and adducts it. 
Thyrohyoid 
Side of thyroid cartilage.. 
Body and greater cornu 
of hyoid bone. 
Hypoglossal 
Elevates larynx. 
Tibialis anticus 
Outer tuberosity and up- 
per part of shaft of tibia. 
Internal cuneiform and 
first metatarsal bone. 
Anterior tibial 
Flexes tarsus and ele- 
vates inner border of 
foot. 
Tibialis posticus 
Shaft of fibula and tibia, 
interosseous membrane. 
Tuberosity of scaphoid, 
internal cuneiform, 
and bases of second to 
fourth metatarsal. 
Posterior tibial 
Extends tarsus and in- 
verts foot. 
Trachelomastoid 
Transverse processes of 
3d to 6th thoracic, and ar- 
ticular processes of last 
3 or 4 cervical vertebrae. 
Mastoid process 
Branches of cervical.. 
Steadies head. 
Transversalis a b- 
dominis. 
Poupart's ligament, iliac 
crest, lower six ribs, lum- 
bar vertebrae. 
Linea alba, pubic crest, 
pectineal line. 
Intercostal, iliohypo- 
gastric, ilioinguinal. 
Compresses viscera and 
flexes thorax. 
Transversalis colli.... 
Transverse processes of 
third to sixth thoracic 
vertebrae. 
Transverse processes of 
five lower cervical ver- 
tebrae. 
Cervical branches 
Keeps neck erect. 
Transversus pedis.... 
Head 5th metatarsal and 
plantar ligaments of met- 
atarsophalangeal joints. 
First phalanx of great 
toe. 
External plantar 
Adducts great toe. 
Transversus perinei.. 
Ramus of ischium 
Central tendon 
Perineal 
Tensor of central tendon. 
Transversus perinei, 
deep. 
See Compressor urethrce. 
Trapezius 
Superior curved line of 
occipital bone, spinous 
processes of last cervical 
and all the dorsal verte- 
brae. 
Clavicle and spine of 
scapula, and a c r o - 
mion. 
Spinal accessory and 
cervical plexus. 
Draws head backward. 
Triangularis sterni... 
Ensiform cartilage, costal 
cartilages of 3 or 4 lower 
true ribs, and sternum. 
Border of inner surfaces 
2d, 3d, 4th, and 5th 
costal cartilages. 
Intercostal 
Expiration. 
Triceps (3 heads) ex- 
tensor cubiti 
External and internal near 
musculospiral groove, 
shaft of humerus; middle 
or long, lower margin 
of glenoid cavity. 
Olecranon process of 
ulna. 
Musculospiral 
Extends forearm. 
Vastus externus 
Anterior border great tro- 
chanter and linea aspera. 
Tuberosity of tibia 
Anterior crural 
Extends leg 
Vastus internus and 
crureus. 
Inner lip of linea aspera of 
femur. 
Tuberosity of tibia 
Anterior crural 
Extends leg. 
Zygomaticus major 
et minor. 
Malar bone 
Angle of mouth 
Facial, infraorbital 
branch. 
Elevates lip outward. 
MUSCLES GROUPED ACCORDING TO 
FUNCTIONS.* 
has its drawbacks, and knowledge of the part actually played 
by individual muscles in the normal activities of the body is 
as yet merely approximate. Owing to the influence of 
gravity, the relations of other muscles to the skeleton, and 
similar factors, a given muscle may perform functions which 
would not be deduced from a simple study of the relations 
of the muscle to the skeleton. Thus the iliacus serves to 
flex not only the hip, but also the knee, and the hamstring 
muscles may flex the hip while flexing the knee. The 
functions ascribed to various muscles in the following tables, 
although an attempt has been made to base them upon the 
more recent work on the action of the muscles, must be taken 
to be merely approximately correct.] 
[The exact functions of many of the muscles have not yet 
been decisively determined. Anatomical studies, the con- 
struction of mechanical models, the electrical stimulation of 
the musculature, and observation of the muscular activities 
of normal individuals and of individuals in whom given 
muscles or sets of muscles are absent or paralyzed, have all 
proved valuable methods of investigation, but each method 
*From Dr. Charles R. Bardeen's article in Morris' 
Anatomy. MUSCLES 
MUSCLES 
1. Facial muscles. 
These serve essentially to contract the various visceral 
orifices of the head or to retract the tissue surround- 
ing them. 
Ear. 
Retractors: Attrahens aurem, attollens aurem, and 
retrahens aurem. 
Orbit. 
(a) Retractor: Occipitofrontalis. The levator pal- 
pebrse superioris, innervated by the third cranial 
nerve, serves to raise the upper lid of the eye. 
(b) Contractors: Orbicularis palpebrarum, corruga- 
tor supercilii and pyramidalis nasi. 
Nasal orifice. 
(a) Dilators: Levator labii superioris alseque nasi, 
transverse portion of the compressor naris, and 
the dilatores naris. 
(b) Contractors: Compressor naris and the depressor 
alee nasi. 
Oral orifice. 
(a) Retractors: 
Upward; Zygomaticus major and minor, leva- 
tor labii superioris, levator labii superioris 
alseque nasi. 
La teral ward: Zygomaticus major, levator 
anguli oris, risorius, platysma myoides, de- 
pressor anguli oris, buccinator. 
Downward: Depressor anguli oris, depressor 
labii inferioris, platysma myoides. 
(b) Contractors: Orbicularis oris. 
(c) Protractors of the lips: Part of the orbicularis 
oris, levator menti. 
2. Muscles acting on the eyeball. 
To adduct the pupil: Internal rectus. 
To abduct the pupil: External rectus 
To rotate the pupil upward: Superior rectus, in asso- 
ciation with the inferior oblique. 
To rotate the pupil downward: Inferior rectus, in asso- 
ciation with the superior oblique. 
3. Muscles acting on the lower jaw. 
(a) To raise it: Masseter, temporal, internal pterygoid. 
{b) To lower it: External pterygoid, digastric, mylo- 
hyoid, geniohyoid, and the infrahyoid muscles. 
The weight of the jaw also plays a part in this 
movement. 
(c) To protract it: External pterygoid and internal 
pterygoid. 
(d) To retract it: The inferior dorsal portion of the 
temporal, the digastric, mylohyoid, and genio- 
hyoid. 
(e) To produce lateral movements: The external ptery- 
goid acting on one side carries the jaw toward the 
opposite side. The masseter draws it slightly 
toward the side on which the muscle lies. This 
action of the masseter is overcome by the internal 
pterygoid (Riegner). 
4. Muscles acting on the hyoid bone. 
(a) To elevate it: Digastric, stylohyoid, styloglossus, 
mylohyoid, geniohyoid, genioglossus, hyoglossus, 
and the middle constrictor of the pharynx. 
(b) To depress it: Thyrohyoid, sternohyoid, omo- 
hyoid, sternothyroid. 
(c) To protract it: Genioglossus (inferior portion), 
geniohyoid, anterior belly of digastric, and the 
mylohyoid. 
(d) To retract it: Posterior belly of digastric, stylo- 
hyoid, and the middle constrictor of the pharynx. 
5. Muscles acting on the larynx. 
(a) To elevate it: Thyrohyoid, stylopharyngeus, 
palatopharyngeus, the inferior constrictor of the 
pharynx, and the elevators of the hyoid bone. 
(b) To depress it: Sternothyroid, sternohyoid, and 
omohyoid. 
(c) To approximate the vocal cords: Lateral crico- 
arytenoid, posterior cricoarytenoid (in conjunc- 
tion with the preceding muscle); internal thyro- 
arytenoid, external thyroarytenoid; transverse 
arytenoid. 
(d) To make the vocal cord tense: Cricothyroid, lateral 
cricoarytenoid, posterior cricoarytenoid, trans- 
verse arytenoid. 
(e) To widen the rima glottidis: Posterior cricoaryte- 
noid. 
(/) To relax the vocal cord: External thyroarytenoid, 
internal thyroarytenoid. 
6. Muscles acting on the tongue. 
(a) To elevate it: Styloglossus (especially along the 
sides), palatoglossus, glossopharyngeus, and the 
elevators of the hyoid bone. 
(6) To depress it: Genioglossus (in the center), hyo- 
glossus (at the sides), chondroglossus, and the 
depressors of the hyoid bone. 
(c) To protrude it: Genioglossus (middle and inferior 
portions). 
(d) To retract it: Genioglossus (anterior portion), 
styloglossus, chondroglossus. 
(e) To shorten it and make it bulge upward: Superior 
and inferior lingual. 
(/) To narrow it and make it bulge upward: Transverse 
lingual. 
(g) To flatten it: Vertical lingual. 
When the muscles work symmetrically, these movements 
are symmetrical; when they do not work symmetri- 
cally, the tongue is moved from side to side, rotated, 
etc. 
7. Muscles acting on the palate and pharynx. 
(a) To narrow the pharyngeal Opening of the Eustachian 
tube: Levator palati. 
(b) To widen the isthmus of the Eustachian tube: 
Levator palati. 
(c) To open the tube: Tensor palati. 
(d) To raise and shorten the uvula: Azygos uvulse. 
(e) To depress the soft palate: Palatoglossus, palato- 
pharyngeus. 
(/) To make tense the soft palate: Tensor palati. 
(g) To lift the soft palate: Levator palati. 
(h) To approximate the anterior pillars of the fauces: 
Palatoglossus. 
(i) To approximate the posterior pillars of the fauces: 
Palatopharyngeus, superior constrictor of the 
pharynx. 
(j) To constrict the pharynx: Superior, middle, and 
inferior constrictors. 
(k) To widen the pharynx: Stylopharyngeus and the 
muscles which protract the hyoid bone. 
(I) To elevate the pharynx: Stylopharyngeus, palato- 
pharyngeus. 
8. Muscles acting on the head. 
(a) To flex it: The supra- and infrahyoid muscles 
(except the posterior belly of the digastric), rectus 
capitis anticus major and minor. 
(5) To extend it: Sternocleidomastoid, trapezius, 
splenius capitis, trachelomastoid, complexus, 
obliquus capitis superior, rectus capitis posticus 
major and minor, and the posterior belly of the 
digastric. 
(c) To bend it laterally: Sternocleidomastoid, rectus 
capitis lateralis, splenius capitis, trachelomastoid, 
complexus, obliquus capitis superior. 
(d) To rotate it: Sternocleidomastoid, trapezius, 
splenius capitis, trachelomastoid, complexus, 
obliquus capitis superior and inferior, rectus capi- 
tis posticus major and minor. 
9. Muscles acting on the spinal column. 
(a) To flex it: Sternocleidomastoid, longus colli, 
rectus capitis anticus major, psoas major and 
minor, scaleni, rectus abdominis, obliquus abdomi- 
nis externus and internus, levator ani, coccygeus 
and sphincter ani. 
(6) To extend it: Splenius capitis, splenius colli, erector 
spinae, semispinalis dorsi, semispinalis colli, com- 
plexus, multifidus spinse, rotatores, interspinales, 
levatores costarum, quadratus lumborum. 
(c) To bend it laterally and rotate it: Sternocleido- 
mastoid, scaleni, longus colli, trapezius, levator 
anguli scapulae, splenius capitis and colli, semi- 
spinalis dorsi, semispinalis colli, complexus, multi- 
fidus spinse, rotatores, intertransversales, leva- 
tores costarum, psoas major and minor, quadratus 
lumborum, obliquus abdominis externus and 
internus, and rectus abdominis. 
10. Muscles of respiration. 
Quiet inspiration: The external intercostals, anterior 
portion of internal intercostals, diaphragm. 
Enforced inspiration: In addition to the muscles men- 
tioned above, the scaleni, sternocleidomastoid, 
serratus posticus superior and inferior, rhomboids, 
serratus anticus, latissimus dorsi, pectoralis major 
and minor, and the extensors of the spinal column. MUSCLES 
MUSCLES 
Quiet expiration: Posterior part of internal intercostals, 
subcostals, and triangularis sterni. 
Enforced expiration: In addition to the muscles men- 
tioned above, the abdominal muscles, sacrolum- 
balis, and the quadratus lumborum. 
The chief muscles of respiration are the intercostals; 
the diaphragm plays a minor part (Fick). 
11. Muscles acting on the abdomen. 
(a) Constriction of the abdominal cavity: Obliquus 
abdominis externus and internus, the transversalis 
and rectus abdominis, and the diaphragm, levator 
ani, and coccygeus. 
(b) Reduction of pressure in the abdominal cavity: The 
muscles of inspiration, with the exception of the 
diaphragm, serve to lessen the compression of the 
abdominal viscera. 
12. Action of the muscles of the perineal region. 
(a) To close anal canal: Sphincter ani externus. 
(b) To constrict the anal portion of the rectum: Levator 
ani (pubococcygeal portion). 
(c) To constrict the bulbus urethrae and the corpus 
cavernosum urethrae (corpus spongiosum): Bulbo- 
cavernosus. 
(d) To elevate the prostate gland: Levator ani. 
(e) To constrict the vagina; Bulbocavernosus, levator 
ani (pubococcygeal portion). 
(J) To cause erection of penis and clitoris: Ischio- 
cavernosus, bulbocavernosus, and compressor 
urethrae. 
(g) To compress the urethra and Cowper's gland: 
compressor urethrae and the transversus perinei. 
(A) To support and lift the pelvic floor: Levator ani, 
coccygeus, transversus perinei. 
13. Muscles acting on the shoulder-girdle. 
The two joints acted upon are the sternoclavicular 
and the acromioclavicular. The movements pro- 
duced consist in lifting and lowering the shoulder, 
carrying it forward and backward, and rotating it. 
(a) Elevation: Levator anguli scapulae, trapezius (up- 
per portion), sternocleidomastoid, rhomboidei, 
serratus magnus (middle portion), omohyoid. 
(b) Depression: Trapezius (lower portion), pectoralis 
major (lower portion), pectoralis minor, sub- 
clavius, latissimus dorsi. The weight of the 
limb is likewise a factor. 
(c) Forward movement: Serratus magnus, pectorales 
major and minor. 
(d) Backward movement: Trapezius, rhomboidei, la- 
tissimus dorsi. 
(e) Rotation: 
Associated with abduction of the arm: Serratus 
magnus (inferior portion), trapezius (superior 
part), levator anguli scapulae. 
Associated with adduction of the arm: Rhom- 
boidei, trapezius (inferior part), serratus magnus 
(upper part), pectoralis major (pectoral portion), 
latissimus dorsi. 
14. Muscles acting on the arm at the shoulder-joint. 
(a) To abduct it: Deltoid, supraspinatus, biceps (long 
head). The inferior part of the serratus magnus 
and the superior part of the trapezius are impor- 
tant in the early stages of abduction of the arm; 
the clavicular portion of the pectoralis major in 
supraabduction. 
(b) To adduct it: Pectoralis major, latissimus dorsi, 
teres major, coracobrachialis, triceps (longhead). 
To these should be added the weight of the limb. 
(c) To flex it: Pectoralis major, deltoid (anterior por- 
tion), subscapularis, coracobrachialis, biceps 
(short head), and the serratus magnus. 
(d) To extend it: Deltoid (posterior portion), teres 
major, latissimus dorsi. The upper and middle 
portions of trapezius, and the levator anguli 
scapul® play an important part in extension of 
the arm. 
(e) To rotate it outward: Infraspinatus, teres minor, 
and possibly the posterior portion of the deltoid. 
(/) To rotate it inward: Subscapularis, deltoid (an- 
terior fibers), teres major, latissimus dorsi, and 
pectoralis major. 
15. Muscles acting on the forearm at the elbow-joint (ar- 
ranged in order of force exerted according to W. 
Grohmann). 
(a) Flexion at elbow: 
Forearm supinated: Brachialis, long head of 
biceps, supinator longus, short head of biceps, ex- 
tensor carpi radialis longus, pronator radii teres, 
flexor carpi radialis, extensor carpi radialis 
brevis, palnaaris longus. 
Forearm in mid-position or pronated: Brachialis 
anticus, supinator longus, long head of biceps, 
short head of biceps, extensor carpi radialis 
longus, pronator radii teres, flexor carpi radialis, 
extensor carpi radialis brevis, palmaris longus. 
(6) Extension at elbow: Triceps, anconeus. 
(c) Pronation of forearm: 
Forearm extended: Pronator radii teres, flexor 
carpi radialis, pronator quadratus, palmaris 
longus. 
Forearm at right angles: Pronator radii teres, 
supinator longus, flexor carpi radialis, pronator 
quadratus, extensor carpi radialis longus, pal- 
maris longus. 
Forearm flexed: Pronator radii teres, supinator 
longus, flexor carpi radialis, pronator quadratus, 
extensor carpi radialis longus, palmaris longus, 
(d) Supination: 
Forearm extended: Supinator longus, short head 
' of biceps, long head of biceps, supinator brevis 
extensor carpi radialis longus, extensor ossis meta* 
carpi pollicis, extensor primi internodii, extensor 
secundi internodii pollicis, extensor indicis. 
Forearm at right angles: Short head of biceps, 
long head of biceps, supinator brevis, extensor 
ossis metacarpi pollicis, extensor primi internodii 
pollicis, supinator longus (in pronation), ex- 
tensor secundi internodii pollicis, extensor indicis. 
Forearm flexed: Short head of biceps, long head 
of biceps, supinator brevis, extensor ossis meta- 
carpi pollicis, extensor primi internodii pollicis, 
extensor secundi internodii pollicis, extensor 
indicis. 
16. Muscles acting on the hand at the wrist. 
(a) To flex it: Flexor carpi radialis, palmaris longus, 
flexor carpi ulnaris, long flexors of the thumb and 
fingers, extensor ossis metacarpi pollicis. 
(b) To extend it: Extensor carpi radialis longus and 
brevis, extensor carpi ulnaris, and the extensors 
of the thumb and fingers. 
(c) To abduct it: Extensor carpi radialis brevis and 
longus, extensor ossis metacarpis pollicis, extensor 
primi internodii pollicis, flexor carpi radialis. 
(d) To adduct it: Flexor carpi ulnaris, extensor carpi 
ulnaris. 
17. Muscles acting on the fingers. 
(a) To flex all the joints: Flexor profundus digitorum; 
all but the last: flexor sublimis digitorum; the 
metacarpophalangeal joint only: flexor brevis 
minimi digiti, the lumbricales, and interossei. 
(b) To extend the fingers: Extensor communis digi- 
torum, extensor indicis, extensor minimi digiti; 
to extend the two interphalangeal joints: the 
lumbricales, interossei, and frequently the flexor 
brevis minimi digiti. 
(c) To abduct from the axis passing through the center 
of the middle finger: Dorsal interossei, first two 
lumbricals, abductor minimi digiti. 
(d) To adduct toward this axis: Palmar interossei, last 
two lumbricals, opponens and flexor minimi digiti. 
18. Muscles acting on the thumb. 
(a) To flex all joints: Flexor longus pollicis; the carpo- 
metacarpal and metacarpophalangeal joints: 
flexor brevis, the adductors, abductor brevis; the 
carpometacarpal joints: opponens pollicis, ex- 
tensor ossis metacarpi pollicis. 
(b) To extend all joints: Extensor longus pollicis; the 
carpometacarpal and metacarpophalangeal joints: 
extensor brevis pollicis. 
(c) To adduct: The adductor, flexor brevis, opponens, 
first dorsal interosseous, extensor longus. 
(d) To abduct: The long and short abductors, the ex- 
tensor brevis. 
19. Muscles acting on the pelvis. 
(a) To flex it: Rectus abdominis, obliquus abdominis 
externus and internus, psoas major and minor. 
(b) To extend it: Erector spinse and multifidus spin®, 
(c) To bend it laterally and rotate it: Abdominal 
muscles, quadratus lumborum, and psoas muscles 
acting on one side. MUSCLES, INFLAMMATION 
20. Muscles acting on the thigh at the hip-joint. ■ 
(a) To flex it: Iliopsoas, sartorius, rectus femoris, 
pectineus, gracilis, adductor longus and brevis, 
tensor vaginae femoris. 
(&) To extend it: Gluteus maximus, biceps, semiten- 
dinosus, semimembranosus, adductor magnus. 
(c) To adduct it: Gracilis, pectineus, adductor longus, 
brevis, and magnus, gluteus maximus (lower 
portion), quadratus femoris, obturator externus. 
(d) To abduct it: Gluteus medius and minimus, tensor 
vagina? femoris, gluteus maximus; and when the 
hip is flexed, the pyriformis, obturator internus, 
and gemelli. 
(e) To rotate it inward: Tensor vaginae femoris, 
gluteus medius (anterior portion), gluteus mini- 
mus, iliopsoas. 
(f) To rotate it outward: Pyriformis, obturator in- 
ternus and gemelli, obturator externus, quad- 
ratus femoris, gluteus maximus, gluteus medius 
(posterior portion), sartorius, pectineus, adductor 
longus, brevis, and magnus (superior and middle 
fasciculi), biceps. 
21. Muscles acting on the leg at the knee-joint. 
(a) To flex it: Sartorius, gracilis, semitendinosus, 
semimembranosus, biceps, gastrocnemius, pop- 
liteus. 
(6) To extend it: Quadriceps femoris (the tensor 
vaginae femoris and gluteus maximus through 
the iliotibial band serve to keep the extended leg 
fixed). 
(c) To rotate it inward (when flexed): Sartorius, 
gracilis, semitendinosus, semimembranosus, pop- 
liteus. 
(d) To rotate it outward (when flexed): Biceps. 
22. Muscles acting on the foot at the ankle-joint (arranged in 
order of force exerted, according to R. Fick). 
(a) To flex it: Tibialis anticus, extensor longus digi- 
torum, extensor longus hallucis, peroneus tertius. 
(&) To extend it: Soleus, gastrocnemius, flexor longus 
hallucis, peroneus longus, tibialis posticus, flexor 
longus digitorum, peroneus brevis. 
(c) To invert the foot at the inferior articulation of the 
talus (art. talocalcanea and talocalcaneonavi- 
cularis): soleus, gastrocnemius, tibialis posticus, 
flexor longus hallucis, flexor longus digitorum. 
(d) To evert the foot at the inferior articulation of the 
talus: Peroneus longus, peroneus brevis, extensor 
longus digitorum, peroneus tertius, extensor 
longus hallucis, tibialis anticus. 
(e) To invert the foot at Chopart's (talonavicularcal- 
caneocuboid) joint: Tibialis anticus, tibialis posti- 
cus, flexor longus hallucis, flexor longus digitorum, 
extensor longus hallucis. 
(/) To evert the foot at Chopart's joint: Peroneus longus, 
peroneus brevis, extensor longus digitorum, per- 
oneus tertius. • 
23. Muscles acting on the toes (arranged in order of force ex- 
erted, according to R. Fick). 
(a) To flex all the joints: Flexor longus digitorum, 
flexor accessorius digitorum, and flexor longus 
hallucis; the first interphalangeal and the meta- 
carpophalangeal joints of the four lateral toes: 
flexor brevis digitorum; the metacarpophalan- 
geal joints: the lumbricals, interossei, abductor 
hallucis, adductor hallucis (oblique head), flexor 
brevis hallucis, abductor minimi digiti, flexor 
minimi digiti. 
(6) To extend all joints: Extensor longus digitorum, 
extensor longus hallucis, extensor brevis digi- 
torum, the interphalangeal joints: the lumbri- 
cales, and the adductors and abductors of the big 
and little toes. 
(c) To abduct from an axis passing through the second 
toe: Abductor hallucis, dorsal interossei, abductor 
minimi digiti, first lumbrical. 
(d) To adduct toward this axis: Adductores hallucis, 
plantar interossei, three more lateral lumbricals. 
(e) To draw together the ends of the metatarsals: The 
transverse head of the adductor of the big toe. 
MUSCLES, INFLAMMATION.-See Myositis. 
MUSCLES, INJURIES.-Atrophy of muscles 
arises from want of use, from continued pressure, 
from injury, from interference with the blood sup- 
ply, from disease of the nerves or their centers, or 
from lead-poisoning. Treatment must be accord- 
ing to the cause, with the use of galvanism, pas- 
sive motion, friction, massage, etc. 
Contractions of muscles result from injury, from 
joint-disease, from disease of the nervous system, 
and from malposition of parts. Sudden or gradual 
extension, tenotomy, and myotomy, are the means 
of treatment. Nerve stretching is of value when 
the contraction is spasmodic. 
Dislocation of muscles and tendons is more usu- 
ally the result of accident, associated with chronic 
joint-disease, or of fracture than of solitary injury. 
The long head of the biceps is most often displaced. 
Early in rheumatoid arthritis of the shoulder- 
joint the long head of this muscle is displaced, and 
the tendon absorbed. The muscles of the forearm 
may be dislocated. In treating a dislocated muscle 
or tendon reduction is generally easy, but the dis- 
placement is likely to recur, since the sheath of 
the muscle or tendon has been lacerated. The 
limb should be relaxed to reduce a dislocation of 
this nature, and the tendon manipulated. A 
splint should be applied, so that pressure is made 
on the point of injury, but the muscle is relaxed. 
If firm adhesion of the tendon does not occur in 4 
weeks, operation should be performed, incision 
made, and the edges of the torn sheath freshened 
and sewed with chromic catgut or kangaroo tendon. 
Passive movements may begin at the end of the first 
week. Fibrous tissue forms when the ends of 
divided muscles are widely separated, but when 
the ends are closely approximated, this fibrous 
tissue becomes filled with muscle-fibers resembling 
true muscle. 
Hernia of muscles is treated by incision and 
stitching of the fascia covering the muscle. 
Hypertrophy of muscle arises from excessive use, 
and in pseudohypertrophic paralysis the muscle 
bulk is greatly augmented, but there is less muscle 
structure and more fat and connective tissue. 
Rupture of a muscle may be followed by atrophy. 
A limited rupture is to be treated as a strain, but 
when it is extensive and the ends widely separated, 
it should be incised and sutured with chromic 
catgut, the skin being sewed with silkworm-gut. 
Rest, relaxation, and other means of combating 
inflammation are to be employed. 
A strain is the name given to the condition in 
which there is a small amount of rupture with 
stretching of the muscle. The deltoid, the ham- 
string, the calf, the back, the biceps, and the great 
pectoral muscles are those mostly strained. Strain 
of the pronator radii teres muscle gives rise to the 
"lawn-tennis arm." "Rider's leg" is produced 
by a strain of the adductors of the thigh. Strain 
of the psoas magnus muscle may suggest appendi- 
citis, but there is no local tenderness, abdominal 
rigidity, nor constitutional symptoms. 
The treatment of strains consists in relaxation 
by suitable position, rest by the use of splints, and 
rest in bed, bandages for compression, and the 
application of hot water, hot lead-water and 
laudanum, and of ichthyol. Dover's powder or 
morphin may be used if the pain is excessive. 
Wounds and Contusions.-Contusions of mus- 
MUSCLES, INJURIES MUSCLES, PROGRESSIVE ATROPHY 
MUSCLES, PROGRESSIVE DYSTROPHIES 
cles vary in severity and in extent, and may be fol- 
lowed by suppuration, inflammation, or atrophy. 
Wounds of muscles are open or subcutaneous, 
longitudinal or transverse. W'hen the wound is 
transverse, it is best to unite the gaping edges of 
the muscle by catgut stitches. When the wound is 
longitudinal, drainage should be provided. Rest 
by means of splints, proper position, and relaxation 
are to be obtained, and inflammation combated. 
Bandaging may prevent much swelling, while the 
early use of cold limits the spread of inflammation. 
Lead-water and laudanum are useful. lodin, 
blue ointment, ichthyol, and intermittent heat are 
of value when repair is well advanced. As soon as 
the acute symptoms subside, massage, passive 
motion, stimulating liniments, and galvanism, 
if the reaction of degeneration exists, or faradism, 
if it does not exist, are to be employed. 
MUSCLES, PROGRESSIVE ATROPHY.-Syn- 
onyms.-Wasting palsy; chronic spinal muscu- 
lar atrophy; chronic anterior poliomyelitis; 
Duchenne-Aran's disease. 
Definition.-A slowly progressive wasting and 
atrophy of certain groups of muscles, with symp- 
toms varying in accordance with the variations in 
the pathologic anatomy. 
Etiology.-It is most frequent in males between 
25 and 50 years of age, and in many instances is 
hereditary. A predisposing cause seems to exist 
in those who habitually use one set of muscles 
(muscular strain). Exposure to cold and damp, 
lead-poisoning, syphilis, and injuries to the spinal 
column are other causes. It follows such acute 
diseases as diphtheria, measles, acute rheumatism, 
typhoid and typhus fevers. 
Pathologic Anatomy.-The morbid alterations 
are of two groups-spinal and muscular. 
The spinal changes consist in the atrophy and 
degeneration of the anterior columns, wasting and 
disappearance of the multipolar ganglion cells of the 
anterior horns, with hyperplasia of the neuroglia; 
rarely the hyperplasia extends to the lateral col- 
umns (amyotrophic lateral sclerosis); also wasting, 
atrophy, and degeneration of the anterior nerve- 
roots. 
The muscular changes consist of a progressive 
wasting of the muscular tissue, with increase of 
the interstitial connective tissue. The final re- 
sult is that the muscle is converted into a mere 
fibrous band w'ith numerous fat-cells, the develop- 
ment of this material taking place outside of the 
muscular elements and in the newly formed con- 
nective tissue. 
Symptoms.-The invasion is gradual, the disease 
having been in progress some weeks or months be- 
fore the patient is aware of its existence. Wasting 
usually begins in the hand, the first dorsal interosse- 
ous being the first to be attacked, then the muscles 
of the thenar and hypothenar eminences, then the 
deltoid, and so on from group to group. Often, 
however, the extension is very erratic in its course, 
jumping from one group to another at some dis- 
tance. In the immense majority of cases the dis- 
ease is permanently limited to one or a few groups 
of muscles in the upper, or, more rarely, in the 
lower, extremities. The only muscles not yet 
known to be attacked are those of mastication 
and those that move the eyeball (Roberts). 
Fibrillary contraction is an early symptom, 
continuing more or less marked so long as any 
muscular fibers remain. It consists of wave-like 
movements of the muscles, excited automatically 
by drafts of air or percussion. Coincident with the 
wasting are loss of power, disorders of sensation, 
coolness and pallor of the surface. The natural 
roundness and contour of the body and limbs are 
changed, the bones standing out in unaccustomed 
distinctness, giving the individual the appearance 
of a skeleton clothed in skin. The hand is fre- 
quently the seat of a very singular deformity-the 
"claw-shaped" hand. The electrocontractility is 
preserved so long as muscular fibers remain. 
Diagnosis.-When wasting palsy is fully devel- 
oped, its diagnosis is a simple matter. In its 
early stages a doubt may exist, but attention to 
the history, symptoms, and progress will deter- 
mine the question. 
Syringomyelia often begins with muscular at- 
rophy as a marked symptom, and may be con- 
founded with wasting palsy, the chief points of dis- 
tinction between which are, the loss of power of 
perceiving heat, or, often, to distinguish between 
heat and cold, and the appearance of trophic 
changes, such as a dusky or purplish hue of the 
hands, with a uniform thickness resembling myx- 
edema, the development of blebs and ulcers, and 
changes in the nails. Arthropathies are sometimes 
met with. See Muscles (Progressive Dystrophies). 
Prognosis is very unfavorable, although the 
danger to life is often very remote. The disease 
may be arrested and remain stationary for years. 
Treatment.-Internal medication seems to have 
no effect on the malady, although if mineral poison- 
ing is suspected, potassium iodid should be used, 
and if syphilis is suspected, a course of potassium 
iodid and mercury should be administered. Ar- 
senic, strychnin sulphate, and cod-liver oil, with a 
generous diet, are among the remedies indicated. 
If the disease is the result of over-working any set 
of muscles, these must be allowed a rest. A most 
effective remedy in wasting palsy is, undoubtedly, 
galvanism. See Motor Points. 
Massage is a valuable adjuvant to the electric 
treatment, as are hot sponging and rubbing along 
the spine. 
MUSCLES, PROGRESSIVE DYSTROPHIES.- 
Progressive muscular dystrophy is a term employed 
to designate all forms of progressive muscular weak- 
ness with atrophy, in which the seat of the lesion is 
in the muscle itself. The dystrophies are to be 
distinguished on the one hand from progressive 
spinal muscular atrophy which is due to a chronic 
progressive degeneration of the gray matter of the 
spinal cord, and, on the other hand, from chronic 
multiple neuritis, in which the lesion is in the nerve- 
fibers. If the lesion of a disease characterized by 
progressive muscular weakness and atrophy is 
located in the gray matter of the spinal cord, it is 
called amyotrophy; if it is located in the nerve, it is 
called neural atrophy; if it is located in the muscle 
itself, it is called myopathy. In any case exhibit- 
ing progressive muscular weakness and atrophy MUSCLES, PROGRESSIVE DYSTROPHIES 
it is the physician's first duty to determine whether 
he has to deal with an amyotrophy, a myopathy, 
or a neural atrophy. But it is always well to bear 
in mind that the large multipolar cell in the an- 
terior horn of the cord, with its axis-cylinder proc- 
ess (neuraxon) and the muscle-fibers to which it is 
distributed, constitutes a trophic unit, and that 
a disease process may involve more than one por- 
tion of this trophic unit. It may begin in one, and 
spread to an adjoining portion. Indeed, it is 
questionable whether disease is ever confined 
strictly to one of these three portions of the trophic 
unit. Ordinarily, however, they are chiefly con- 
fined to one portion, thus affording a basis of 
classification. There are cases on record which 
exhibited the symptomatology of amyotrophy 
and myopathy, or neural atrophy at the same 
time, and in which two or all three portions of the 
trophic unit were involved. 
Symptoms.-The progressive muscular dystro- 
phies appear before the age of 18, the majority be- 
fore the age of 10. They are characterized by 
muscular weakness, and eventually by great mus- 
cular atrophy; but in the earlier stages apparent 
enlargement of certain muscles-pseudohypertro- 
phy-is frequently seen. There are no mental or 
sensory symptoms, or these are rare or incon- 
spicuous. Fibrillary twitchings, common in the 
amyotrophic form of progressive muscular atro- 
phy, are, with rare exceptions, absent. The onset 
of the muscular weakness is insidious, and the 
shoulder or pelvic girdle or the legs are first af- 
fected. Unlike the spinal type of progressive mus- 
cular atrophy, the disease almost never begins with 
weakness and atrophy of the small muscles of the 
hand. The dystrophies belong to the so-called 
family diseases. Commonly two or more members 
of a family are affected. Boys are much more 
prone, to be affected than girls. The hereditary 
influence is usually derived from the mother. The 
knee-jerks and the qualitative electric reactions 
are unaltered save in the late stages of the disease. 
The disease progresses until a stage of almost 
complete helplessness is reached. The weakness 
and atrophy become extreme, and various forms 
of club-feet and anteroposterior and lateral cur- 
vature of the spine are seen late in the disease. 
Types.-The different varieties of the muscular 
dystrophies have been much written about, but 
they are really unimportant. These different 
types depend upon the age at which the disease 
appears, and the parts first or most affected, and 
the distribution of the atrophy or hypertrophy. 
These so-called types are merely varieties of the 
dystrophies exhibiting superficial differences, and 
are not in any sense distinct diseases. 
The fact that these various types run into or 
overlap each other, and that different types are 
seen in the same family, offer strong evidence in 
support of this view. For example, one of the 
two brothers shown in the accompanying illustra- 
tions represents one type, while the other brother 
represented another type or a mixture of two types. 
The most important types commonly described 
are these:' 
1. Pseudomuscular hypertrophy. 
MUSCLES, PROGRESSIVE DYSTROPHIES 
2. Juvenile type of Erb. 
3. Facioscapulohumeral type of Landouzy- 
D^j^rine. 
4. The atrophic form. 
Pseudomuscular hypertrophy has, of these vari- 
ous types, been longest, and is best, known. It 
develops slowly, and begins usually before the 
eighth year. The first symptom noticed is some 
clumsiness in walking or running and in going up- 
stairs, due to weakness of the muscles of the calves 
and of the extensors of the knees. The calf- 
muscles, although weakened, become hypertro- 
phied. The infraspinati, the glutei, and the ex- 
tensors of the knee also become hypertrophied. 
The lower half of the pectoralis major and the 
latissimus dorsi are wasted early in the disease. 
This hypertrophy may be very marked or only 
slight. Weakness of the muscles of the back, and 
of those which fix the pelvis upon the thighs, 
Erb's Type of Progressive Muscular Dystrophy. 
produce an anterior curvature of the spine (lor- 
dosis) which may become extreme, so that a per- 
pendicular line, touching the spine between the 
shoulders, and striking the ground, passes 2 or 3 
inches behind the sacrum. When the child sits 
down, this anterior curvature disappears and is 
replaced by a posterior curvature. The gait be- 
comes more and more waddling as the disease pro- 
gresses. Great difficulty is experienced in going 
up-stairs, due especially to the weakness of the 
extensors of the knees. In rising from the floor the 
child gets upon his hands and knees, then places 
one foot upon the floor, then one hand upon the 
knee, the other hand upon the other knee, and 
then, by successive movements, climbs up his own 
thighs in the characteristic fashion first described 
by Gowers. As the disease progresses, the hyper- 
trophied muscles become atrophied. Contrac- 
tures frequently occur, due to the overaction of MUSCLES, PROGRESSIVE DYSTROPHIES 
MUSCLES, PROGRESSIVE DYSTROPHIES 
certain groups of muscles which are no longer 
opposed by their normal antagonists. Thus vari- 
ous forms of club-foot are produced, especially 
talipes equinus. Contractures of the legs upon the 
thighs, and of the thighs upon the abdomen, occur, 
and may become extreme. Sensation remains 
normal. As a rule, no mental changes take place. 
Quantitative, but not qualitative, electric changes 
occur. The knee-jerks are preserved (never exag- 
gerated) until the disease has made considerable 
progress. They fade out gradually as the disease 
progresses. 
The juvenile type of Erb begins with weakness in 
the shoulder girdle. There is atrophy of the thighs 
and upper arms, while the forearms; hands, legs, 
and shoulders preserve their natural contour; 
indeed, there may be some hypertrophy of the del- 
toids, the calf-muscles, and the infraspinati. The 
thin upper arms and the thighs, along with the 
apparently well-developed forearms, deltoids, and 
calf-muscles constitute the striking picture which 
this type of dystrophy presents. This variety of 
dystrophy is well illustrated by the accompanying 
illustration. Eventually all the muscles become 
atrophic. Contractures of the legs and curvature 
of the spine occur, and the child becomes quite 
helpless. The later stage of this type of the dis- 
ease differs little from that of pseudomuscular 
hypertrophy. 
The facioscapulohumeral type of Landouzy- 
Dejerine usually begins in infancy. The dis- 
tinguishing feature is the wasting and atrophy of 
the face-muscles, giving rise to the so-called myo- 
pathic facies. The face presents a mask-like ap- 
pearance, and the lips are protruded and thickened, 
constituting the "Tapir mouth" (bouche de tapier'). 
Neither the ocular muscles nor those of mastication 
or deglutition are affected. The atrophy extends 
to the shoulder and arm muscles. The features 
seen in the preceding type develop. It chiefly 
differs from the Erb type in that the face is in- 
volved and that the onset is at an earlier period of 
life. 
The atrophic type presents the chief features of 
pseudomuscular hypertrophy, differing from that 
type mainly in that there is no hypertrophy, or 
apparent hypertrophy, at any stage of the disease. 
The muscles of the legs and back are first affected. 
The gait, according to Bramwell, is not so waddling 
as that of the pseudohypertrophic form; and he 
has described it as the "spider-crab" gait. This 
form is so nearly identical with the so-called 
Leyden type that the latter need not be described. 
Course and Duration.-The dystrophies are es- 
sentially chronic in their course, which, however, 
varies greatly within certain limits. Ordinarily, 
patients live from 10 to 20 years; but a few cases 
have run a somewhat rapid course in 3 or 4 years. 
On the other hand, some patients have lived al- 
most to old age. When the affection begins in 
early infancy, or the onset is rapid, the probabilities 
are that it will run a comparatively short course. 
The disease seems to progress more rapidly after 
the patient has become so weakened as to be prac- 
tically helpless. 
Etiology.-In about one-half the cases heredity 
has been traced, usually through the mother. 
The disease is so distinctly a family one that it 
must be concluded that its potential possibilities 
are contained in the germ-plasm. This, of course, 
implies some defect in one or both of the parents 
of a patient. 
In the majority of cases the disease appears 
before the age of 10 years. Boys are much more 
frequently affected than girls; but in the Landouzy- 
D^j^rine type boys and girls suffer about equally. 
Pathologic Anatomy.-The primary seat of the 
disease is in the muscles themselves. The term 
"primary muscular dystrophy" is meant to carry 
with it this idea. The anatomic changes are prac- 
tically the same in the different types. Slight 
changes have been found in the spinal cord, very 
different in degree and kind from those found in 
progressive spinal muscular atrophy of the Duch- 
enne-Aran type. Nevertheless, the view is held 
by some that the dystrophies are nervous in origin, 
due to damage to the trophic centers which control 
the nutrition of the muscles. The primary 
changes are found in the muscle-fibers. Atrophied 
and hypertrophied fibers are found, the former 
predominating. There is proliferation of the 
nuclei, and vacuolation and segmentation of the 
fibers. Secondarily, there occurs proliferation of 
the connective tissue, multiplication of its nuclei, 
and increase of adipose tissue. The apparent in- 
crease in size of the muscles is chiefly due to these 
fatty and connective-tissue deposits. 
Diagnosis.-The dystrophies are not difficult of 
recognition if the features which characterize them 
are known. In the following little table the chief 
diagnostic features which separate them from the 
spinal form of progressive muscular atrophy, with 
which they are most apt to be confounded, are enu- 
merated, while those which characterize this last- 
named affection are placed in a parallel column. 
Progressive Muscu- 
lar Dystrophies. 
1. Usually more than 
one member of a 
family affected. 
2. Onset in childhood. 
3. Small muscles of 
hand almost never 
affected first. 
4. Fibrillary twitchings 
rare. 
5. Enlargement of cer- 
tain muscles very 
common. 
6. Qualitative electric 
reactions absent 
until late in the 
disease. 
7. Waddling gait and 
peculiar method of 
rising from floor. 
Progressive Spinal 
Muscular Atrophy. 
1. More than one mem- 
ber of the family af- 
fected very rarely. 
2. Onset in adult years. 
3. Small muscles of 
hand affected first, 
as a rule. 
4. Fibrillary twitchings 
usually present. 
5. No enlargement of 
muscles. 
6. Qualitative electric 
reactions present. 
7. Waddling gait not 
seen. 
When only one member of the family is affected, 
the diagnosis may be difficult or even impossible; 
but usually the remaining features which charac- 
terize the disease are so plain that the diagnosis is MUSCLES, PROGRESSIVE DYSTROPHIES 
MUSCLES, PROGRESSIVE DYSTROPHIES 
not difficult even in the absence of this very signifi- 
cant feature. The slow onset, together with the 
features already named, should serve to distinguish 
the dystrophies from poliomyelitis. From multi- 
ple neuritis they are to be recognized by the 
absence of pain and tenderness, by the normal 
electric reactions, the presence of pseudohyper- 
trophy, the age and manner of onset, and the fam- 
ily history. The various types of the dystrophies 
may be distinguished from each other by the 
points already enumerated. Sometimes this is 
easy, at other times difficult. These types overlap 
or run into each other more or less, and it is some- 
times difficult or impossible to distinguish them 
from each other, nor is it especially important to 
do so. 
Prognosis.-The prognosis is grave. The disease 
is progressive, and a cure is not to be expected. 
Patients may live 10 or 20 years. Those in whom 
the disease begins late in childhood or youth are 
likely to live longer than those in whom it begins 
in infancy. Rapidity of progress, of course, 
points to an earlier termination. After patients 
have become helpless, the progress of the disease 
becomes more rapid. The patient is likely to die 
of an intercurrent malady, such as pneumonia or 
bronchitis. 
Treatment.-Members of dystrophic families 
should be strongly discouraged from marriage. 
Careful hygiene, with plenty of outdoor life, 
should be advised for the brothers and sisters of a 
dystrophic patient. Not a great deal is to be 
expected from the drugs, but more from a plan of 
treatment which includes outdoor life, with careful 
hygiene and measures calculated to promote the 
nutrition of the affected muscles, such as electricity, 
massage, and wisely regulated gymnastics. While 
a cure cannot be effected, the progress of the dis- 
ease may, for a time at least, be stayed, or even a 
distinct improvement may be brought about by 
conscientious, intelligent, and persistent employ- 
ment of these measures. Weiner has recently 
reported a case which was very considerably bene- 
fited by a systematic course of gymnastics lasting 
2 years. While drugs have no special influence 
upon the disease itself, they may, from time to 
time, be indicated by the patient's general condi- 
tion. In the later stages of the disease, after con- 
tractures have occurred, the orthopedic surgeon 
may, by performing tenotomies, produce very 
gratifying relief. 
The Peroneal or Leg Type of Progressive Muscu- 
lar Atrophy.-This affection, both in its symp- 
tomatology and pathologic anatomy, seems to 
stand midway between the dystrophies and the 
spinal form of progressive muscular atrophy. Com- 
monly more than one member of a family is affect- 
ed. The affection is, therefore, a hereditary or 
family disease. It begins in later childhood or 
youth by weakness and atrophy of the muscles of 
the feet and legs, usually in the former first. The 
atrophy and paralysis slowly and steadily increase, 
and, after 3 or 4 years, the upper limbs become 
involved, the small muscles of the hands being 
usually first affected, and then the muscles of the 
forearms. The supinator longus escapes, as do the 
muscles of the shoulder, neck, and face. The bird- 
claw hand seen in the spinal type of progressive 
muscular atrophy may be produced when the 
hand atrophy has become extreme. Patients rise 
from the floor by climbing up their own thighs, as 
do those affected with progressive muscular dys- 
trophies; but as the disease progresses they 
become unable to rise from the floor at all; and 
this may occur before the arms have become appre- 
ciably involved, as is the case in the patient repre- 
sented in the accompanying figure. Contractures 
of the muscles of the legs occur rather early, and 
produce talipes equinus or equinovarus. Fibril- 
lary twitchings may occur, and slight sensory dis- 
turbances with pains are occasionally present. 
The powers of coordination are not only unim- 
paired, but rather increased. The patient may be 
able to walk long after he is unable to rise from the 
The Peroneal or Leg Type of Progressive Muscular 
Atrophy. 
Patient aged 20. The legs are greatly wasted, but the arms 
are unaffected. A sister aged 25 suffers from the same dis- 
ease in a more advanced form. Neither can rise from the 
floor unaided. 
floor unaided, and when the slightest push suffices 
to upset him. The knee-jerks are diminished or 
lost. The affected muscles exhibit the electric 
reactions of degeneration. The affection has a 
tendency to follow acute infectious diseases. 
Only a few autopsies have been made. Changes 
in both the peripheral nerves and spinal cord have 
been found. Whether the disease is due to a 
neural atrophy or an amyotrophy, or to both, is 
not yet positively known. The disease is to be 
recognized by the family history of the patient, by 
the mode and time of life of onset, the absent knee- 
jerks, the changes in the electric reactions of the 
muscles, the fibrillary twitchings, the presence of MUSCULAR RHEUMATISM 
MYCETOMA 
club-feet, and, in the late stages, of the bird-claw 
hands. The course of the disease is slow, chronic, 
and progressive. Treatment is to be carried out 
along the lines laid down in cases of progressive 
muscular dystrophies and progressive spinal mus- 
cular atrophies. 
MUSCULAR RHEUMATISM.-See Rheuma- 
tism (Muscular). 
MUSCULAR SENSE.-The sensation by which 
we are aware of the degree of force exerted by 
contracting muscles. It differs from (1) pain on 
firm pressure; (2) pain on tetanic contraction 
(cramp), and (3) the sense of muscular fatigue. 
Disorders of this sense are those of hyperesthesia 
and anesthesia. Diminution is most frequent, 
with or without loss of voluntary power. Muscu- 
lar anesthesia rarely requires special treatment. 
A sudden local loss of muscular sense requires rest 
and counterirritation, and is usually dependent on 
a local lesion in the cord. Faradization may be 
useful in some cases. See Locomotor Ataxia. 
MUSHROOMS, POISONING.-The most common 
fungus which gives rise to urgent symptoms of 
poisoning is the fly-fungus, or Amanita muscaria, 
the active principle of which is muscarin. Several 
other species of fungi possess poisonous properties. 
Severe cases resemble in their symptoms the algid 
stage of cholera; collapse, cyanosis, and muscular 
contractions preceding a fatal termination. 
The stomach should be washed out immediately, 
if a siphon-tube or stomach-pump is obtainable; 
otherwise an emetic of apomorphin hydrochlorid, 
gr. 1/8, hypodermically; or of zinc sulphate, 20 
grains in water, or mustard, 1/2 of an ounce in 
tepid water, or other emetic, may be administered. 
The physiologic antagonist of muscarin, which is 
atropin, should be given at once in the form of the 
tincture of belladonna, 20 minims in water, or 
injected hypodermically as atropin, 1/60 to 1/20 of 
a grain, and it may be repeated, if necessary. 
Castor oil is the best purgative, and should be 
given as soon as possible. When depression exists, 
stimulants in the form of brandy, ether, or ammo- 
nia may be administered. External heat is to be 
employed, and, for some days after symptoms have 
disappeared, the patient should remain in bed. 
MUSK (Moschus).-The dried secretions from 
the preputial follicles of the musk-deer of Thibet, 
having an odor of marked penetrating power. It 
occurs in irregular, unctuous grains, of reddish- 
brown color and bitter taste. Its odor is destroyed 
by drying, but returns again on the addition of 
moisture. Trituration with camphor or hydro- 
cyanic acid also destroys it. There is a variety 
known as Chinese musk which is very valuable 
when in pods or sacs, but all varieties are much 
adulterated. That sold in shops is impure, and if 
sold for less than 25 cents a grain, it is probably 
worthless. 
It is a diffusible stimulant and supportive, an 
antispasmodic and nerve sedative. The dose is 2 
to 6 grains, and is not to be employed save to 
carry a patient past a crisis. Rectal injections in 
starch-water may be used in low fevers, when the 
strength of a patient is fast failing, and theie are 
nervous symptoms indicative of great depression. 
It is also of value in nervous excitement or nervous 
collapse. 
Tincture of Musk, 5 percent. Dose, 20 to 80 
minims. 
A stimulant in croup: 
3. Musk, gr. iv 
Powdered white sugar, 5 j. 
Divide into 6 powders; give 1 powder every 
hour or half-hour. 
MUSSEL POISONING.-The toxic effects in 
man sometimes resulting from eating mussels, 
especially the Mytilus edulis. See Fish-poison- 
ing, Ptomain-poisoning. 
MUSTARD (Sinapis).-Official under the two fol- 
lowing titles but the pharmacopoeial preparations 
are directed to be made from black mustard only. 
Sinapis Alba, White Mustard-the seed of Sina- 
pis alba. Dose, as emetic, 1 to 3 drams. 
White mustard contains myrosin, a ferment, and 
sinalbin, a crystalline substance, sinapin, an 
alkaloid, erucic or brassic acid, and a bland, fixed 
oil. 
Sinapis Nigra, Black Mustard-the seed of 
brassica nigra. Dose, as emetic, 1 to 2 drams. 
Black mustard contains myrosin, a ferment, and 
sinigrin (potassium myronate), sinapin, an alka- 
loid, erucic, or basssic acid, and a bland, fixed oil. 
Sinapis is much used locally in the form of the 
well-known "mustard plaster." 
A mustard plaster is a valuable counterirritant 
in the treatment of pain in the abdomen or chest. 
It should be made by mixing mustard flour in 
varying proportions with ordinary flour, and 
moistened by warm vinegar or water. Half 
mustard and half wheat flour will suffice if the skin 
is tender, but for children one-fourth mustard is 
strong enough. To make a mustard plaster, place 
a piece of heavy muslin or linen on a newspaper, 
over which smear the mustard mass. Over this a 
thin piece of linen should be placed, to prevent 
adhesions to the skin and to modify the irritant 
effect. The edges of a newspaper may be folded to 
resemble a picture-frame, and the plaster placed 
within this, giving it a support. 
Mustard burns are peculiar in their slowness to 
heal, and in the fact that they are tender and 
reddened for days. When the burning is excessive, 
a piece of lint soaked in lime-water and olive oil, 
or in olive oil alone, may be used to give relief. 
Vaselin may be smeared over the burn. 
Preparations.-Oleum S. Volatile, a colorless or 
pale yellow liquid, of pungent, acrid odor and 
taste and neutral reaction, almost insoluble in 
water but freely soluble in alcohol and in ether. 
Dose, 1/8 to 1/4 minim. Charta S. Mustard Paper, 
consists of black mustard, the fixed oil removed 
by percolation with benzin, mixed with solution of 
rubber and spread on paper. Each square inch 
should contain about 6 grains of mustard. For 
local use. 
MYALGIA.-See Rheumatism (Muscular). 
MYASTHENIA GRAVIS.-See Paralysis 
(Asthenic Bulbar). 
MYCETOMA (Fungus Disease of India; Madura MYCOSIS FUNGOIDES 
MYELITIS 
Foot).-A tropical disease probably due to the 
vegetable parasitic fungus of the actinomyces 
group-streptothrix mycetoma. The seat of the 
disease is usually strictly localized in the foot, 
which becomes intensely swollen, deformed, and 
studded with cysts and sinuses which emit an 
offensive, oily, seropurulent fluid. Prophylaxis 
probably consists chiefly in the wearing of shoes. 
Treatment is solely surgical-amputation should 
be performed well above the diseased part, though 
in the early stages it may be sufficient to incise or 
remove with the curette all the diseased tissue. 
MYCOSIS FUNGOIDES (Granuloma Fungoi- 
des).-A chronic, malignant, infectious disease, 
characterized primarily by an eruption of an urti- 
carial, eczematoid, or lichenoid appearance, and 
later by ulcerating fungoid tumors. In the early 
or " premycotic" stage the affection begins as an 
urticarial, erythematous, eczematous, or lichenoid 
eruption, accompanied by itching and burning. 
After a duration of some months or years this is 
followed by flat or slightly elevated plaques of a 
pinkish-red color. 
In the second stage there appear pea-sized to 
fist-sized, reddish or violaceous, shining tumors, 
which may develop from the above-described 
plaques or may spring up independently. They at 
times develop with remarkable rapidity, and spon- 
taneously disappear just as quickly. More com- 
monly they become an abscess, ulcerate, and pre- 
sent the appearance of a mushroom or fungoid 
growth. The microscopic appearance strongly 
resembles that of the round cell and lymphosar- 
coma. The result is almost invariably fatal. 
To relieve the itching quinin and antipyrin have 
been found of value. .Recently radium has been 
used with success. 
MYDRIASIS.-See Pupil. 
MYDRIATICS AND CYCLOPLEGICS. Defini- 
tion.-A mydriatic is an agent which produces 
dilatation of the pupil. A cycloplegic is an agent 
which produces paralysis of the ciliary muscle of 
the eye. In ophthalmology these two terms are 
usually considered interchangeable, as the ordinary 
drugs possessing the power of producing mydriasis 
also produce, in a greater or less degree, cyclo- 
plegia. 
The mydriatics which have been used in the 
examination of the eye are atropin, belladonna, 
homatropin, cocain, hyoscyamin, duboisin, datu- 
rin, scopolamin, muscarin, mydrin, euphthalmin, 
and ephedrin. Atropin and homatropin are the 
drugs usually employed in refraction, and are those 
to be recommended, as they have been extensively 
used and their action and dangers are far better 
understood than those of the newer substances. 
Physiologic Action.-Atropin and homatropin 
produce mydriasis by paralyzing the sphincter of 
the pupil and stimulating the dilator at the same 
time. Cocain affects the dilator of the pupil 
chiefly, stimulating it. Atropin paralyzes the 
ciliary muscle completely, and leaves the eye ad- 
justed only for the far-point. Homatropin para- 
lyzes it less completely, but sufficiently for the pur- 
poses of refraction, when administered in the man- 
ner indicated. Cocain has a very slight paralytic 
action on the ciliary muscle. As usually adminis- 
tered, the effect of atropin lasts from 10 days to 2 
weeks; of homatropin, from 1 to 2 days; of cocain, 
only a few hours. 
Indications in Refraction.-In all first refractions 
of the eyes of persons under 45 or even 50 years of 
age, in whom there is no suspicion of glaucoma. 
No absolute diagnosis of the finer grades of astig- 
matism can be made without a mydriatic in a 
person possessing the power of accommodation. 
Dangers.-These drugs may precipitate an 
attack of glaucoma in the eye of a person past 
middle life, or in whom there is already a tendency 
to increased intraocular tension. It has been said 
that if a mydriatic ordinarily applied for purposes 
of diagnosis produces glaucomatous symptoms, 
the patient would likely have been the subject of 
insidious glaucoma later in life anyway, and that 
the early diagnosis by the mydriatic facilitates 
treatment. 
Mydriatics may also cause general toxic symp- 
toms in susceptible patients. The general symp- 
toms are tickling and dryness in the throat, vomit- 
ing, diarrhea, redness of the face, and quick and 
irregular pulse; even fatal cases have been re- 
corded. If there is any history of idiosyncrasy, the 
patient should always be instructed to press the 
finger against the lacrimal sac for 10 minutes after 
using the drops. This danger may also be averted 
by using minute or divided drops of the solution. 
Congestion of the conjunctiva is often a temporary 
result of the instillation of a mydriatic. The 
systemic effects of a mydriatic may be combated 
with a full dose of paregoric. 
Administration.-The most effective of this class 
of drugs, and that most frequently used, is the sul- 
phate of atropin. A solution of 1 grain to 2 drams 
is ordinarily prescribed; 1 drop of this strength 
solution is placed in each eye 3 times daily for 2 
days prior to the examination. An additional 
drop is generally applied at the office of the oculist 
before beginning the examination. For the reason 
of its prompt action and the short duration of its 
effect, the hydrobro mid of homatropin offers a very 
efficient and necessary substitute for atropin in 
office practice. It is, however, a much more 
expensive drug than the sulphate of atropin. The 
best solution is a mixture of two-thirds hydro- 
bromid of homatropin, 10 grains to the ounce, and 
one-third hydrochlorid of cocain, 10 grains to the 
ounce. A drop of the mixed solution is instilled 
in each eye every 10 minutes for an hour preceding 
examination. If it is necessary to have repeated 
examinations of the eye or to have prolonged 
mydriasis, atropin should invariably be used. 
Cocain is useful to dilate the pupil, to facilitate 
ophthalmoscopic or retinoscopic examination, but 
is valueless as a cycloplegic. The 4 percent solu- 
tion is generally used. Sufficient dilatation is 
usually obtained in from 15 to 30 minutes. 
Hyoscyamin, duboisin, daturin, and scopolamin 
are sometimes used, but investigation has not yet 
definitely established reason why they should be 
preferred to the older drugs. 
MYELITIS.-An inflammation which affects the 
substance of the spinal cord, and which may be MYELITIS 
MYELITIS 
limited to the gray or white matter, involving the 
whole or isolated portions of the cord. When the 
gray matter alone is inflamed, it is termed central 
myelitis; when the white matter and the meninges, 
it is termed cortical myelitis. It may be ascend- 
ing, descending, or transverse in its extension. 
The disease is characterized by more or less sudden 
and complete loss of motion and sensation. In 
the acute form the symptoms appear suddenly; in 
the subacute they develop in 2 to 6 weeks, in the 
chronic a longer time elapses. 
Etiology.-It follows spinal meningitis; exposure 
to cold and damp; injuries to the vertebrae; 
tumors; caries; prolonged functional activity of the 
cord; typhus fever; rheumatism; syphilis; puer- 
peral fever; or, during the course of the exan- 
thems, arsenical or mercurial poisoning. 
Symptoms.-The severity of the symptoms 
depends upon the extent and location of the in- 
flammation. The onset is usually sudden, with a 
chill, fever (103° F.), frequent pulse, with altera- 
tions in sensibility and motility: pain in the back, 
aggravated by touch and by heat and cold, with 
sensations of formication ("pins and needles"), 
the limb feeling as if asleep, or else complete anes- 
thesia, associated with severe neuralgic pains, 
The distinction between anesthesia (insensibility 
to touch) and analgesia (insensibility to pain) must 
be clearly determined. There is a sensation of 
constriction around the body and limbs, as if 
encircled by a tight cord-"the girdle pains"- 
and rapidly developing paraplegia, complete in a 
few hours, with involuntary discharges. The 
reflex functions are usually abolished, as seen by 
attempting to cause movement of the limbs by 
tickling the feet or by striking the patella tendon; 
rarely are they diminished, very rarely exagger- 
ated. The temperature of the affected limbs is 
lowered 3 or 4 degrees. Sloughs and bed-sores 
and muscular atrophy result if the anterior 
cornua-the trophic centers-are affected. The 
foregoing symptoms, with rectal and vesical 
paralysis, are associated with more or less pro- 
nounced vomiting, hepatic disorders, irregularity 
of the heart, dyspnea, dysphagia, apnea, and pain- 
ful priapism. The urine is markedly alkaline in 
reaction, finally developing cystitis. Among the 
late manifestations are shooting pains and spas- 
modic twitchings or contractions of one or all of 
the museles of the paralyzed parts. The electro- 
contractility is abolished in the paralyzed parts. 
Diagnosis.-Acute spinal meningitis is distin- 
guished from acute myelitis by severe pains, in- 
creased by pressure, with muscular contractions, 
increased by motion, followed by paralysis much 
less profound than the paraplegia of myelitis; in 
spinal meningitis there exists cutaneous and mus- 
cular hyperesthesia which is absent in myelitis. 
Congestion of the spinal cord is characterized by 
the mild character and short duration of all the 
symptoms. 
Hemorrhage in the spinal canal is abrupt, with 
irritative symptoms, slight paralysis, preserved 
reflexes, and electrocontractility. 
The principal diagnostic points of acute myelitis 
are the "girdle" around the limbs or body, rapid 
and complete paraplegia, loss of sensation, lowered 
temperature in the affected parts, early and per- 
sistent sloughing (bed-sores), and alkaline urine 
or cystitis. 
Hysteric paraplegia shows no trophic changes, no 
altered reflexes, slight atrophy, irregular anesthesia 
and the presence of the stigmata of hysteria. 
Lithemic paresthesia, tingling and numbness of 
fingers and toes, might lead to error if the cerebral 
symptoms of lithemia are overlooked. 
The diagnosis of the location of the lesion is 
made by a study of the height of the anesthesia, 
the skin reflexes, and the distribution and extent of 
the paralysis. 
The following table by Morton Prince will be 
helpful in showing what portion of the cord is 
involved: 
Lumbar 
Myelitis. 
Dorsal 
Myelitis. 
Cervical 
Myelitis. 
Paralysis 
Sensa- 
tion. 
Atrophy. 
Electrical 
reaction. 
Bladder. 
Bowels.. 
Reflexes, 
sup er- 
ficial. 
Reflexes, 
deep. 
Priapism. 
Paraplegia 
Pains in legs, or 
girdle pains 
around loins; 
hyperesthetic 
zone around 
loins; anesthe- 
sia of legs, 
complete or 
uneven dis- 
tribution. 
Of legs 
Reaction of de- 
generation in 
atrophied 
muscles; or, 
in mild cases, 
quantitati v e 
diminution. 
Incontin e n c e 
from paralysis 
of sphincter. 
Incontin e n c e 
from paral- 
ysis of sphinc- 
ter, disguised 
by constipa- 
tion. 
Lost 
Lost 
1. Dorsal, ab- 
dominal, and 
intercostal 
muscles, ac- 
cording to 
height of les- 
ion. 2. Leg. 
Girdle pain and 
hyperesthet i c 
zone between 
ensiform car- 
tilage and 
pubes. 
Of dorsal and 
abdominal 
(and intercos- 
tal muscles, 
not subject to 
examination) 
corresponding 
to height of 
lesion; some- 
times mild and 
slow of legs. 
R. d. in dorsal 
and abdominal 
muscles; slight 
quantit a t i v e 
changes only 
in legs when 
wasted. 
Retention, or 
intermi 11 e n t 
inconti n e n c e 
from reflex ac- 
tion; later from 
overflow. Cys- 
titis common. 
In vo 1 u n t a r y 
evacuation 
from reflex 
spasm, or con- 
stipation. 
Temporary loss, 
then rapid in- 
crease. 
Temporary loss, 
then slow in- 
crease. 
Often present... 
Neck muscles, 
diaphragm, 
arms, trunk, 
and legs. 
Hyperesthe s i a 
and pains in 
certain nerve 
distributions 
of arms; be- 
low this, anes- 
thesia of arms, 
body, and legs. 
Atrophy of 
neck muscles 
(rare) or more 
commonly of 
arms. 
R. d. in atro- 
phied muscles. 
Same as in 
dorsal myelitis. 
Same as in dor- 
sal myelitis. 
Same as in dor- 
sal myelitis. 
Same as in dor- 
sal myelitis. 
Often present. MYELOCELE 
MYOPIA 
Prognosis varies according to the location of the 
lesion and the completeness of the symptoms. 
If the paralysis is of the ascending variety, death 
occurs within a few days, from paralysis of the 
muscles of respiration. If the trophic centers are 
affected, there occur bed-sores, intense pyelone- 
phritis and cystitis, and changes in the joints, with 
death from exhaustion in several weeks. Central 
myelitis, or inflammation of the gray matter, is 
rapid in its progress, death occurring in a week or 
two. The morbid process may be arrested and 
the general health restored, but some spinal 
symptoms will persist. 
Treatment.-Absolute rest is essential to secure 
even a palliation of the symptoms. Locally, con- 
siderable relief follows the use of hot-water bags, 
or sponges dipped in hot water, and applied along 
the spine every few hours. The remedies most 
strongly recommended are digitalis, strychnin, 
iron, mercury, and the iodids. Electricity is of 
little value. Cystitis and bed-sores must be 
guarded against. 
MYELOCELE.-See Spina Bifida. 
MYELOMA.-The myeloid or giant-celled sar- 
coma. See Sarcoma, and Bone (Tumors). 
MYIASIS.-See Parasites (Animal). 
MYOCARDITIS. -See Heart-disease (Organic). 
MYOCLONIA.-See Paramyoclonus Multi- 
plex. 
MYOMA.-A muscular tumor. Also an affec- 
tion marked by the growth in the skin of small, 
sessile, freely movable, isolated, reddish tumors 
consisting of involuntary muscular fibers. If small 
and multiple, they are called liomyomata; if there 
is but a single large tumor, it is called a dartoic 
myoma; if the tumors contain much fibrous tissue, 
they are called fibromyomata; if vascular and 
erectile, angiomyomata; if the lymphatics are in- 
volved, lymphangiomyomata. See Tumors. 
MYOMECTOMY.-The excision of a uterine 
fibroid without removal of the uterus. This opera- 
tion is applicable to certain classes of uterine 
fibroids. When the tumor is pedunculated and 
subperitoneal, the pedicle may be ligated in two 
parts and the tumor removed; if it has no pedicle, 
the capsule may be incised and the tumor enu- 
cleated. The uterine wound should then be closed 
with interrupted sutures. 
The operation of myomectomy is of value when 
the conditions are favorable, since the patient is 
cured without removal of the uterus. A danger- 
ous complication of myomectomy is hemorrhage. 
See Uterus (Fibroma). 
MYOPIA (Near-sightedness).-A condition of the 
eye in which parallel rays of light are brought to a 
focus in an eye at rest in front of the retina. 
It is most often dependent on the lengthening 
of the axial diameter of the eye, and such cases are 
called true or static myopia. A false or functional 
myopia is produced by spasm of the ciliary muscle, 
conic cornea, swelling of the lens in incipient 
cataract, etc. In such cases the sclera is of usual 
thickness, and the axis of the eyeball is not length- 
ened; the change is in the refractive media. See 
Ametropia. 
Etiology.-It is rarely congenital, and, when so, 
it may be hereditary. An anatomic cause is said 
to be the peculiar construction of the orbit in cer- 
tain persons. Devitalization and weakened resist- 
ance of the ocular tissues are predisposing causes. 
Scrofulous children are ready victims to myopia. 
The early necessity for increased convergence and 
accommodation by the precocious application of 
hyperopic eyes of childhood to continuous near- 
work produces a hyperemia of the ocular tissues, 
which, if of low resisting power, are stretched, 
the eye gradually becoming lengthened, and, as a 
result, myopic. Myopia is often seen in persons of 
intellectual pursuits requiring excessive near-work, 
such as students, artists, engravers, etc. However, 
in the congenital and hereditary types, the patients 
may be of the most ignorant classes of mere manual 
laborers. In such cases a low-grade choroiditis 
is an important etiologic factor. Myopia rarely 
results from an increased refractive power of the 
lens in the early stages of cataract in old persons, 
and to this fact may be possibly attributed the 
cases of so-called "second sight," in which aged 
persons find themselves able to read again without 
their convex lenses. However, their distance- 
vision becomes markedly decreased. The entire 
eyeball is not necessarily involved in myopia: as, for 
instance, myopia results from the condition known 
as conic cornea, the relation between the retina 
and other media being normal. 
An occasional and a curious cause of myopia 
is a marked decrease in weight of an extremely 
stout emmetrope or a low degree hyperope. In a 
like manner there has been noticed considerable 
decrease of myopia in persons who suddenly and 
markedly increase in weight. 
Disadvantages and Dangers.-The axial diame- 
ter being too long, the parallel rays of light falling 
on the eye focus in front of the retina, and hence 
only a blurred image of external objects, is received 
on the rods and cones. In moderate hyperopia a 
similar defect is overcome by the accommodation, 
but the myopic eye possesses no mechanism adapted 
to the correction of the refractive error. There 
is no way of diminishing the refractive power of the 
dioptric system, and hence distant objects are 
always blurred. There is false estimation of size 
and distance, and altogether the myope is at a 
decided disadvantage in sports or occupations. 
However, the myope is still able to see near 
objects distinctly, and, unfortunately, therein lies 
his greatest danger. Deprived of many outdoor 
pleasures, he seeks occupation and amusement 
within his own limited circle of vision. By hold- 
ing his book or implements close to his eye, he is 
able to see distinctly; but in so doing he strains his 
power of convergence excessively, producing ocu- 
lar congestion and compression of the eyeball; 
and by bending over he affords a favorable posi- 
tion for the distention of the ocular veins. The 
coats of the eyeball, already of weakened resist- 
ance and put upon the stretch, are further pulled 
and damaged. The eyeball becomes more and 
more lengthened, and the myopia increases. With 
the stretching of the ocular coats the nutrition of 
the eye is seriously disturbed, and, as a result, the 
choroid becomes diseased, and this causes associate MYOPIA 
MYOPIA 
retinal changes, defective vision, even with proper 
glasses, resulting. The nutrition of the vitreous 
and lens is also seriously damaged. The conse- 
quences of such denutrition in the highly myopic 
eye are serious, and these eyes are liable to cata- 
ract, vitreous opacities, and retinal detachment. 
The danger is, of course, greatest in youth. 
Contrary to the popular impression, the myopic 
eye should be considered as a "sick eye." How- 
ever, if proper glasses are prescribed and con- 
stantly worn and excessive near-work interdicted, 
a moderate degree of myopia unaccompanied by 
posterior staphyloma is not liable to progress, but 
will remain more or less stationary through adult 
life. This again offers another argument for the 
early correction of myopia. 
Another danger of excessive convergence in a 
myopic child is divergent squint. The strain in 
excessive convergence, necessitated by the dimin- 
ished distance for near-work and extra effort to 
rotate the elongated eyeballs, may be so great 
that the effort to converge both eyes is finally 
relinquished, and one eye diverges. 
A final danger of myopia is the liability to acci- 
dents on account of the inability to see distant 
objects clearly. 
Progressive or malignant myopia is the serious 
type in which the ocular coats continue to stretch 
and become devitalized until they ultimately give 
way. The bulging occurs at the weakest portion, 
near the posterior pole, to the temporal side of the 
disc, and constitutes what is known as posterior 
staphyloma. The destruction of the choroid is 
accompanied by many conditions which are readily 
recognized through clear media with the ophthal- 
moscope. The myopic crescent is caused by 
the absence of the pigment of the stretched cho- 
roid and retina, usually at the nasal margin of the 
disc, allowing the sclerotic to show through as a 
white crescent. Other white spots indicative of 
chronic choroiditis may be seen scattered through- 
out the fundus. Hemorrhages and extravasations 
sometimes produce retinal detachment. In severe 
cases the vitreous becomes fluid and the eyeball 
soft. Vitreous opacity and luxation of the lens 
may result. With such serious sequels we readily 
see that the ultimate result of unchecked malignant 
myopia may be disorganization of the whole eye 
and total blindness; and in all cases of high myopia, 
whether progressive or stationary, there are patho- 
logic changes of such import as to produce more or 
less amblyopia. 
Symptoms.-The objective symptoms in the 
Iqwer grades of myopia are of little importance. 
In the high degrees the eyeballs may be prominent, 
and when strongly converged, are seen to be elon- 
gated. In such cases the pupils are large and inac- 
tive. The myopic crescent and the choroidal 
condition help in forming the diagnosis. 
The most noticeable subjective symptom is the 
interference with vision. In moderate myopia 
distant objects cannot be seen distinctly. Myopic 
children complain that they cannot see the clock 
across the room or distinguish writing on the 
blackboard at school, although they are able to 
read at close range with apparent ease. In ex- 
treme cases of myopia or in the progressive type 
the far-point is so close to the eye as to render 
the eye virtually useless for distant vision. Sco- 
tomata, limitation of the visual field, vitreous 
opacities, photophobia, photopsia, muscse, and 
ocular pains are additional symptoms of the higher 
degree of myopia. 
As a rule, the symptoms of accommodative 
asthenopia and the remote reflex irritations from 
eye-strain are not complained of in myopia, as the 
ciliary muscle is passive rather than active. Its 
radial fibers are better developed, and are greatly 
in excess of the circular fibers, the opposite of the 
condition in hyperopia. However, because of the 
strain on the convergence, evidences of muscular 
asthenopia, such as headache, weariness and sense 
of heat in the eye, and chronic conjunctivitis, may 
follow. 
Diagnosis rests upon the diminished acuteness of 
distant vision, the ophthalmoscopic examination 
(refraction and fundus changes), the retinoscopic 
examination, and the acceptance of and visual 
improvement by a concave lens. Conic cornea is 
easily differentiated from myopia by the peculiar 
protruding appearance of the cornea, the depth of 
the anterior chamber, and the characteristic 
retinoscopic reflex. Hyperopia with ciliary spasm 
simulating myopia is readily differentiated under 
mydriasis. See Retinoscopy. 
Treatment.-Prophylactic measures consist in 
the careful examination of children's eyes, particu- 
larly about the time they are to start to school, and 
in securing the best hygienic conditions for them 
during their school hours. Good ventilation, 
properly constructed desks, and sufficient and 
rightly directed light are requisites for the main- 
tenance of normal vision. There should be a north 
light coming in over the left shoulder, and not fall- 
ing directly on the desks. The walls and ceilings 
should be painted in light colors. There should 
be 1 foot of window space for every 5 feet of floor 
space, and small type should be distinctly read in 
the most remote corner of the school-room on a 
cloudy day. Books should be printed in large, 
broad-faced type, and on dull-faced paper. The 
desks should be sloping and so arranged as to 
avoid all stooping positions. In young myopes 
excessive near-work must be interdicted. Such 
children should be urged to forego studying, read- 
ing, and other indoor amusements, and must be 
encouraged to go out into the open air and take 
plenty of healthful exercise, meanwhile rigorously 
wearing their correcting glasses. 
In myopia the book, writing, etc., should be 
placed at a distance of at least 13 inches from the 
eye, artificial or insufficient light should be avoided, 
and the eyes should be given frequent intermissions 
of rest. 
In the progressive type of myopia, and in 
the extremely high degrees, near-work must be 
virtually excluded from the daily occupation. In 
such cases the treatment depends upon rest, absti- 
nence from near-work, constitutional and hygienic 
measures, the relief of any increased ocular tension 
by the administration of eserin or by iridectomy, 
attention to the associate choroiditis and other MYOSITIS, INFECTIOUS 
pathologic changes, and the constant use of cor- 
recting lenses. 
Prescription of Glasses.-Ordinarily, it is desir- 
able to prescribe spectacles that will give fair dis- 
tant vision and, at the same time, enable the 
patient to read easily at the proper working dis- 
tance. However, in cases of persons doing much 
near-work, a pair of weak lenses may be ordered for 
reading, etc., and stronger glasses for outdoor use, 
theaters, receptions, etc. 
In myopia of 3 diopters or over the far-point is 
inside of the ordinary reading distance, and there 
is necessarily extra convergence; but, unfortu- 
nately, there is no necessity for accommodation; 
the adductors are deprived of this stimulus, and 
exophoria results. In order to cause the requisite 
accommodative stimulus to the adductors, con- 
stant use of the full correction of myopia has been 
urged. The theory of this is plausible, but the 
strain on the undeveloped accommodation is too 
severe, and serious asthenopia results. Unfortu- 
nately, most myopes complaining of unsatisfactory 
glasses are wearing not only their full correction, 
but are, in a majority of cases, over-corrected. A 
myope will naturally select a strong lens, and cau- 
tion should be observed in the trial with the test- 
lenses, accepting as the proper refraction the weak- 
est lens which gives normal vision, and which does 
not diminish the size of the letters, and, as the 
patients so often say, makes them appear better 
but further away. 
In prescribing glasses for constant use some 
deduction from the full correction should be made 
in cases of children and young adults, in order 
that compromise lenses may be continually used 
which give fair distant vision, but which necessi- 
tate only a moderate accommodative effort in 
reading. It must always be remembered that 
overcorrected myopia may produce as distressing 
symptoms as uncorrected hyperopia. 
At the presbyopic age bifocal lenses should be 
constantly worn and the full distance-correction 
ordered in the upper segment. In the high degrees 
of myopia (above 6 to 8 diopters) the full correction 
is never tolerated. In the unfortunate cases of ex- 
tremely high myopia (12 to 20 diopters), with ex- 
tensive choroidal changes, glasses are often of 
little service in making a useful working eye, and 
are so bulky and heavy as to be uncomfortable. 
Removal of the Lens for High Myopia.-It is a 
well-known fact that the removal of the crystalline 
lens makes an emmetropic eye hyperopic by about 
10 or 12 diopters. In the knowledge of this fact it 
has been suggested that removal of the lens would 
be an advisable procedure in cases of extremely 
high myopia: for instance, of from 15 to 20 diopters. 
Although this operation has been performed a num- 
ber of times, the actual practical results are not 
definitely settled; there is great danger of retinal 
detachment, and, moreover, it is too radical a 
treatment to be advised to the beginner in oph- 
thalmology. An ideal indication for this opera- 
tion would be lenticular myopia. 
MYOSITIS, INFECTIOUS.-An inflammation of 
voluntary muscles due to obscure infection; it 
may be acute or subacute, purulent or nonsup- 
purative. It is characterized by tenderness, 
slight edema, and swelling. Frequently an ery- 
thema appears over the body. It is differentiated 
from trichiniasis by examination of the muscle 
fragments, and by blood examination (eosinopilia 
being present in trichiniasis). 
MYOSITIS OSSIFICANS.-A progressive con- 
genital affection, usually first manifested in 
boyhood, and seldom seen in females. Masses of 
bone develop in the muscles, chiefly those of the 
back, producing deformity, eventually impeding 
respiration and so causing death in about ten 
years. It is often associated with irregular epiphys- 
eal ossification, and with the absence or ill-develop- 
ment of the proximal phalanx of the thumb and 
great toe. It is believed that the connective- 
tissue of the muscle undergoes ossification while 
the true muscle fibers atrophy, but the pathology 
of the disease is quite obscure, and no treatment is 
of avail. A similar condition known as myositis 
ossificans traumatica may develop after severe in- 
jury. It is most common in the quadriceps ex- 
tensor group in the thigh and in the muscles of the 
arm. In this form the ultimate prognosis is good. 
Cases in which operation is done late, after the 
osteoid tissue has ceased to grow, do well as a rule, 
but if operation is done early there is a decided 
tendency toward recurrence (Finney). As a 
prophylactic measure incision, and evacution of 
the effused blood, with drainage of the affected 
area, is recommended. 
MYOTICS.-See Miotics. 
MYOTONIA CONGENITA (Thomsen's Disease). 
-A rare congenital disease appearing in early 
childhood and in family groups, characterized by 
tonic spasms of the muscles when voluntary move- 
ments are made. The muscles are developed out 
of proportion to their power. 
The facial, ocular and laryngeal muscles are 
rarely affected. There is rarely mental defect. 
The electrical reaction of the muscles involved 
is slow and associated with vermicular contractions 
between the poles-the myotonic reaction of 
Erb. The disease is incurable. 
MYRISTICA (Nutmeg).-The kernel of the ripe 
seed of M. fragrans. Its properties are due mainly 
to the volatile oil. It is an aromatic stomachic 
and tonic, and in large doses a powerful narcotic. 
Dose, 5 to 15 grains. The oil is sometimes em- 
ployed as a rubefacient in paralysis and rheuma- 
tism, and is much used as a condiment. M., 
Oleum, the volatile oil. Dose, 1 to 5 minims. 
MYRRH.-A gum-resin obtained from the 
Commiphora myrrha, a tree of Arabia. It occurs 
in dark-colored, brownish-red, irregular shaped 
tears, having an agreeable aromatic odor and a 
bitter acrid taste. In medicinal amount it is 
stimulant to the circulation, and to uterine and 
bronchial mucous membranes. Dose, 5 to 15 
grains. M., Tinct., diluted with water or with 
potassium chlorate, is used in ulcerative stomatitis, 
spongy gums, acute pharyngitis, and in ptyalism. 
It is combined with other remedies for the treat- 
ment of chronic bronchitis, and in combination 
with iron is efficient in functional amenorrhea. 
In leukorrhea and chronic cystitis it is of service. 
MYRRH MYXEDEMA 
The pure tincture is sometimes applied with a 
small brush to spongy or tender gums, and it is of 
use as a gargle in ulcerated sore throat. Dose, 
10 to 30 minims. 
In stomatitis: 
1$. Tincture of myrrh, gtt. xx 
Potassium chlorate, 3 j 
Elixir of calisaya, § iij. 
Give a teaspoonful in water every 4 hours. 
MYXEDEMA. Definition.-A disease charac- 
terized by the infiltration of the connective tissues 
of the body with a mucus-like substance and by 
atrophy of the thyroid gland. 
Etiology.-The cause of the disease is the ina- 
bility of the thyroid gland to perform its function, 
usually through atrophy. Rarely, it may be 
observed after removal of the gland. It is more 
common in women. Heredity is important, par- 
ticularly in the maternal line. 
Morbid Anatomy.-The connective tissue of the 
skin and subcutaneous tissues are infiltrated with 
a jelly-like substance containing mucin. The fib- 
rillar and cellular elements of connective tissue 
are increased. Both of these processes may affect 
glands, muscles, nervous system, and the outer 
coats of the arteries. The thyroid gland is usually 
found to be atrophied. 
Pathology.-With the atrophy or degeneration 
of the thyroid gland a hitherto undetermined some- 
thing which is necessary for the well-being of the 
organism fails to be elaborated, and the changes 
enumerated occur. The secondary changes in 
organs result from the vascular degeneration. 
Symptoms.-The face is swollen, rounded, with 
features less marked, and expressionless. The 
hands are spade-like and the feet misshapen; the 
body is bulky. The skin is thrown into folds, 
especially around the neck, and is dry, scaly, and 
thickened. The intellectual processes are sluggish, 
drowsiness is a quite constant symptom, and in- 
sanity often supervenes. The speech is slow. 
Myxedema in childhood, whether congenital or 
acquired, is termed cretinism. Subnormal tem- 
peratures, particularly in the later stages, are the 
rule. 
Diagnosis.-The edema of chronic cardiac and 
renal disease is distinguished from this by the pit- 
ting and diminished hardness on pressure. The 
facies is not to be confounded with that of renal 
and cardiac disease, of which other physical signs 
are present. 
Myxedema is distinguished from akromegaly in 
the great preponderance of instances in women, its 
development later in life, the absence of changes in 
bones, the full-moon face, the swollen and clubbed 
fingers, and the peculiar pale, waxy, boggy, and 
shining skin. 
Prognosis.-The course of the disease is slow, 
and death from intercurrent affections is not un- 
usual. Since 1892 the use of thyroid extract has 
modified the hitherto generally accepted opinion 
that the disease was of necessity fatal. 
Treatment.-The patient should be protected 
from cold; hot baths, friction, and massage, with 
subcutaneous injections of pilocarpin, assist in 
maintaining the action of the skin. Inasmuch as 
the thyroid gland is found to be atrophied or 
degenerated in cases of this disease, and total re- 
moval of the gland is often followed by cachexia 
strumipriva (operative myxedema), the logical 
treatment consists in supplying to the organism 
that secretion essential to normal metabolism 
which in health is elaborated by the thyroid gland. 
The inconvenience of gland implantation, sheep's 
thyroids being used, is sufficiently obvious. The 
injection of minced, raw, or slightly cooked sheep's 
thyroids, although successful in ameliorating the 
symptoms of the disease, speedily produced an 
insurmountable repugnance to them, so that their 
use was very generally abandoned. At present 
the glycerin extract, powdered extract, or a pre- 
sumably active principle of the gland are the only 
ones employed. The glycerin extract is given by 
the mouth in daily dose of from 15 to 30 minims, 
representing from one-eighth to one-fourth of an 
average sheep's thyroid. If this seems to be inef- 
fective, the amount should be increased until 
evidence of betterment is obtained. The initial 
dose should be maintained at semiweekly or weekly 
intervals until all symptoms of the disease have 
disappeared. Inasmuch as the substance which 
the thyroid supplies is essential to the health of the 
organism, continual administration of the remedy 
is necessary during the remainder of the patient's 
life, but at more infrequent intervals. The pow- 
dered gland may be given by the mouth in such 
doses that from one-eighth to one-third of a sheep's 
thyroid is represented; in amount it is usually 5 
grains. Inasmuch as the salts and extractives in 
the gland have been shown to be useless, attempts 
have been made to isolate the active principle and 
at the same time to get rid of the products of de- 
composition which may be harmful. Fresh thyroid 
gland contains but one iodin-containing substance 
-the colloid matter-which consists of a proteid 
part (possibly a globulin) combined with an organ- 
ic compound of iodin (crude iodothyrin), and the 
latter can be separated from the colloid by hydrol- 
ysis. Since the specific effects of the thyroid 
gland can be obtained either from the colloid or 
the separated iodothyrin, the latter is now chosen 
for thyroid administration. At present there is no 
satisfactory way of standardizing the thyroid prep- 
arations, but the average dose of colloid matter is 
11/2 grains. 
On the administration of preparations of the 
thyroid gland in myxedema it has been found that 
untoward and even poisonous symptoms may arise. 
If, during its use, subnormal temperature, slow 
pulse, and mental hebetude are observed, the dose 
should be increased. Further, the dose should be 
larger in cold than in warm or hot weather. If, 
however, the pulse becomes quicker, evidences of 
circulatory disturbances arise, febrile reaction is 
marked, the patient becomes excitable, either the 
dose is too large or products of decomposition of 
proteid material are present as impurities. In the 
first case the dose should be diminished or the 
remedy stopped for a time; if the second, another 
preparation must be chosen. Symptoms of 
MYXEDEMA MYXEDEMA 
MYXOMA 
cardiac paralysis and circulatory disorder are more 
likely to occur in postoperative myxedema (thy- 
roidectomy for goiter). In this instance the heart 
must be carefully observed, and at the first signs 
of failure the remedy omitted, while strychnin, 
strophanthin, or nitroglycerin is employed; a 
combination of the first and last is the most useful. 
Since most of the instances of the ill-advised use of 
thyroid extract have occurred in the practice of 
surgeons, it is proper that this phase of the treat- 
ment should be delegated entirely to physicians. 
With care in the use of preparations of the thyroid 
gland their administration may be safely continued 
during the life of the patient. For other pre- 
cautions and accidents the reader is referred to 
Thyroid Treatment. 
MYXOMA.-A connective-tissue tumor the 
consistency of which is similar to the jelly of 
Wharton of the umbilical cord. It consists of a 
gelatinous, mucin-containing intercellular sub- 
stance, in which are scattered peculiar branched or 
stellate cells. See Tumors. NABOTHIAN CYSTS 
NAILS, DISEASES 
N 
NABOTHIAN CYSTS.-See Cervix Uteri (En- 
docervicitis). 
N2EVUS. See Nevus. 
NAILS, DISEASES.-Affections of the nail may 
be divided into those of the nail proper, and those 
of the soft parts in relation with the nail. Altera- 
tions in the texture of nails are not common. 
Alterations in form result from injury or skin- 
disease. The general state of health influences the 
growth of the nails, and after illness a deficient 
formation of horny matter may result, manifested 
by the production of a groove across the nail. 
The breadth of this groove roughly indicates the 
period and duration of illness. 
Onychia is an inflammation of the matrix of a 
nail. The best-known form is of syphilitic origin, 
and is either subacute or fully developed. The 
subacute form is attended with pain, redness, and 
more or less ulceration of the matrix. The devel- 
oped form is met with in adults. The nail soon 
rots and crumbles away at the root, leaving a 
ragged border attached to the distal portion of the 
finger. The free edges also suffer, and become 
broken and fissured. 
The treatment includes attention to the primary 
disease. Hot moist dressings or poultices are 
suitable in almost all cages of acute inflamma- 
tions, and may be followed by soothing antiseptic 
lotions and ointments. 
Carbolic acid, 1 dram, with water, 4 ounces, 
makes a soothing antiseptic lotion, which may 
be poured on lint and wrapped around the last 
joint of the finger. Chloral, 5 to 10 grains, with 
1 ounce of water, may also be used. Finely 
powdered lead nitrate makes an excellent remedy. 
Ointments of boric acid, of tar, of mercury, or 
red precipitate salve may be used. A free applica- 
tion of a strong solution of silver nitrate at. the 
beginning of the inflammation will often prove 
curative. When granulations spring up, they 
may be covered with tannin or alum, or rubbed 
daily with a crystal of copper sulphate, or strong 
carbolic acid or the liquor ferri persulphatis ap- 
plied. In chronic inflammations of parts around 
the edges, daily painting with a solution of silver 
nitrate, 10 grains to 1 fluidounce, is useful. These 
measures failing, removal of the portion of the 
nail at fault or of the whole nail may be performed. 
Malignant onychia requires removal of the entire 
nail, cauterization of the matrix, and dressing with 
iodoform gauze, and the internal use of tonics 
and nourishing diet. 
Syphilitic onychia is best treated with black 
or yellow wash, a weak solution of corrosive 
sublimate, by dusting with calomel, or by apply- 
ing calomel ointment. Internal antisyphilitic 
measures are to be employed coincidently, and 
in strumous subjects constitutional treatment is 
also needed. 
Paronychia, or whitlow, is an acute inflammation 
of the tissues around the matrix. It is generally 
of traumatic origin, and should be incised. In the 
milder forms the arm may be placed in a sling 
and the finger kept constantly wet with some 
weak antiseptic lotion, such as boric acid. Boric 
acid ointment may be used when the inflammation 
has subsided. Tonics, especially those contain- 
ing quinin, are to be given internally. See 
Paronychia. 
Ingrowing Nails.-Though occasionally on the 
fingers, ingrowing nails are most frequently found 
on the great toe, as the result of wearing tight 
boots and of cutting the nails square. A tight boot 
presses the skin over the sharp corner of the nail 
on each side, and ulceration ensues. There is 
lateral hypertrophy of the edge of the nail, or the 
soft tissues are forced over the margin of the nail. 
The pain caused by walking is often very severe. 
Treatment.-In mild or trivial cases the trim- 
ming or clipping of the free margin of the nail, 
scraping of the dorsal surface with the edge of a 
bit of glass or with a knife, so as to reduce its 
thickness and to produce a tendency to curling 
upward or backward of its lateral margins, and the 
removal of any cuticle accumulated under the in- 
growing edges of the nail are all that is required to 
give relief and prevent further progress. Pressure 
must be avoided. When ulceration has occurred, 
a minute roll of lint shreddings should be neatly 
packed beneath the tender overhanging skin and 
Subungual Exos- 
tosis of the Great 
Toe.-{Spencer and 
Gask.) 
The End of a Great 
Toe to Show the Charac- 
teristic Appearance of 
a Subungual Exostosis. 
-{Spencer and Gask.) 
ingrowing edge. Strapping is then so applied as 
to retain the lint and drag upon the overhanging 
integument and keep it pulled away from contact 
with the ingrowing edge. The lint may be 
removed in a few days and the space filled with 
boric acid, iodoform, lead nitrate, alum, or zinc 
oxid. Exuberant granulations may be destroyed by 
silver nitrate, copper sulphate, perchlorid of iron, 
or pure carbolic acid. Repeated applications 
may destroy the sharp ingrowing edge of the nail. 
Under local anesthesia the nail may be split, 
the offending portion removed, together with the NAPHTHALENE, 
NECK, INJURIES 
soft tissue and the adjacent matrix, and the 
wound antiseptically dressed. A somewhat popu- 
lar operation is to remove a V-shaped piece of the 
side of the toe in which the nail is ingrown, in- 
cluding in the V the section of offending nail. 
The cut surfaces are drawn together with sutures, 
and the wound is dressed antiseptically. 
Subungual exostosis forms a painful swelling 
which raises the middle while the two sides of the 
nail are unaltered. It generally affects the great toe. 
Complete removal of the ungual phalanx with 
the nail and nail-bed is the only satisfactory meas- 
ure, the plantar surface being turned over as a flap. 
NAPHTHALENE, Naphtalin. C1OHS-A hy- 
drocarbon obtained from coal-tar, formed during 
the manufacture of ordinary coal gas. Chemically, 
it is one of the benzene derivatives. When redis- 
tilled, it crystallizes in colorless, rhomboid plates, 
of slightly tarry but strong odor, and burning, 
aromatic taste; insoluble in water, soluble in 15 
of alcohol, very soluble in boiling alcohol, ether, 
chloroform, carbon disulphid, and fixed or volatile 
oils. It is seen frequently in the form of moulded 
blocks, under such names as alabastrin and cam- 
phylen, for preserving furs and flannels from 
moths, and for disinfecting urinals. Dose, 1 to 3 
grains, in emulsion, or as a powder with sugar 
in wafers or capsules. 
Naphthalene is employed as an antiseptic for 
the intestinal canal in typhoid fever, diarrhea, both 
acute and chronic, tuberculous diarrhea, and dysen- 
tery. It renders the urine aseptic and may be 
employed in vesical catarrh. It is used internally 
for bronchial asthma, verminous affections, the 
chronic pulmonary catarrh of the aged, and chronic 
bronchitis with copious secretion. It is said to 
be effective as a teniacide, also as a vermifuge for 
seat-worms given by injection, 15 to 30 grains in 
3 ounces of olive oil. Burned in the patient's 
room it has given excellent results in pertussis, 
giving force to the belief that the well-known 
benefit resulting from taking children to gas- 
works for whooping-cough is due to the naphtha- 
lene fumes rather that to those of the gas-tar. 
Locally, naphthalene has high value as an antiseptic 
for indolent ulcers, sloughing wounds, open cancers, 
and pus cavities. Painted over organic remains 
it effectually prevents the ravages of insects, and 
has largely supplanted camphor for protecting 
woolen clothing from moths. 
NAPHTHOL (Beta-naphthol).-A phenol oc- 
curring in coal-tar, but usually prepared from 
naphthalene. It is one of several naphthols, and 
occurs in colorless, shining, crystalline laminae, or a 
whitish, crystalline powder, of faint, phenol-like 
odor, and sharp taste. Soluble in 3/4 of alcohol, 
in about 1000 of water, and in 75 of boiling water; 
very soluble in boiling alcohol, ether, chloroform, 
olive oil, and petrolatum. Used as ointment, 1 to 5 
for adults, but for children it should not be over 2 per- 
cent strength. Dose, 3 to 6 grains in cachet or pill. 
Beta-naphthol is used in the form of a 2 percent 
soap in prurigo, herpes, ichthyosis and favus, also 
in a 1/2 to 5 percent alcoholic solution, or as a 10 
percent ointment, for hyperidrosis, scabies, and 
eczema, but it is a dangerous and irritant applica- 
tion. Internally it has been employed in typhoid 
fever, dilatation of the stomach, intestinal dys- 
pepsia, diarrhea and dysentery. Its germicidal 
rank is probably second to many other agents, but it 
is an efficient internal antiseptic, being practically 
nontoxic in medicinal doses. Dose, 3 to 6 grains. 
NARCOPHIN.-A double salt, being the meco- 
nate of morphin and of narcotin. It is mainly used 
in connection with Twilight Sleep, q.v. 
NARCOTICS.-See Hypnotics; Lambert Treat- 
ment for Narcotic Addiction. 
NARCOTIN.-An alkaloid of opium, said to be 
sudorific and antipyretic, but it has no narcotic or 
hypnotic effects. Dose', 1 to 2 grains. See 
Opium. 
NARGOL.-A compound of silver and nucleinic 
acid, containing 10 percent of silver, used in 1 to 5 or 
10 percent solutions. It is more stable than protar- 
gol and less irritant in solutions of equal strength. 
NASAL BONES.-See Nose (Injuries). 
NASAL DISEASE.-See Nose (Caries); Rhinitis. 
NAUHEIM TREATMENT.-See Heart-Dis- 
ease, Organic. 
NAUSEA OF PREGNANCY.-See Pregnancy 
(Diagnosis, Pernicious Vomiting). 
NAVEL.-An oval fossa of variable depth on the 
median fine of the anterior abdominal wall. The 
cicatricial eminence at its bottom indicates the 
place where the umbilical cord was detached. See 
Umbilical Cord. 
NEAR-SIGHTEDNESS.-See Myopia. 
NECK, INJURIES.-Burns are particularly se- 
rious on account of the swelling and the edema of 
the larynx which may complicate them. Even 
when no deeper than the skin, they result in cica- 
trices which are most deplorable because of the 
appearance of the parts and because of the devia- 
tions they cause, sometimes binding the chin down 
to the sternum; for this reason they should be 
grafted at the earliest possible time. Deep burns 
extending to the muscles and to the vessels are 
most serious, even when limited, for obvious 
reasons. The cicatrices pass into keloids more 
often than in other regions. 
Contusions are not frequent; they are usually 
produced by falls, blows, hanging, garrotting, 
throttling, the passage of a wheel over the neck, or 
by the pressure of the dislocated clavicle. A blow 
on the side of the neck is a great aim with pugilists, 
because it is almost a sure knock-down or knock- 
out; it is often grave in its results, because of the 
importance of the organs of the neck, and may be 
accompanied by fractures of the hyoid bone, 
larynx, and trachea, injuries to muscles, vessels, 
nerves, pharynx, esophagus, vertebral lesions, 
concussions, and contusions of the spinal cord; 
hematoma may form and become large and cause 
grave pressure-symptoms on all the structures. 
Death may occur after a few days from edema of 
the lungs; also from embolism from one of the 
large vessels of the neck. 
Wounds of the neck are comparatively rare in 
civil practice; sometimes they are accidental and 
due to a fall on a fragment of glass, a stem of iron 
or wood; they are most commonly due to attempts 
at murder or suicide. Suicidal wounds are the NECK, INJURIES 
NECK, INJURIES 
most common and the most interesting. The 
wounds are penetrating or nonpenetrating accord- 
ing to whether or not they reach the trachea, or 
the. esophagus, or the vessels. Superficial or 
extrafascial wounds of the neck-i. e., wounds not 
extending beyond the superficial cervical fascia- 
present nothing peculiar. However, a large in- 
cised wound of the external or anterior jugular, 
especially if these veins happen to be unusually 
large, may give entrance to air. In tracheotomy 
the anterior jugular and the inferior thyroid veins 
are often wounded. If the parallelism of the lips 
of the wound has been disturbed, there may be 
much infiltration of blood; this requires enlarge- 
ment of the incision and ligation, in preference to 
pressure; cellulitis spreads rapidly. 
Gunshot wounds are rare, yet there are instances 
when a bullet has traveled under the skin and 
above the fascia without penetration of the fascia. 
Contused and lacerated wounds, if extensive, may 
be followed by cicatrices and their consequences. 
Gunpowder stains should receive as careful atten- 
tion as those of the face, especially if in the exposed 
parts of the neck. Gunshot wounds causing much 
destruction of skin present the same remarks as 
the lacerated wounds. 
Deep or subfascial wounds-that is, wounds ex- 
tending beyond the cervical fascia, and more or 
less deeply-are almost all very serious because of 
the almost invariable injury of some of the large 
vessels and nerves, or of the special organs of the 
neck, larynx, trachea, pharynx, and thyroid body, 
giving passages to air, food, and blood, each of 
which calls for special treatment. 
Complications of the wounds of the neck are the 
following: Thrombus or extravasation of blood, 
due to the loss of parallelism of the lips of the 
wound through the various layers; entrance of air 
into the veins, more frequent and dangerous here 
than anywhere else; passage of food through the 
wound and into the larynx or trachea; hemorrhage, 
more or less profuse, according to the vessel injured 
and its accessibility; emphysema, due to injury of 
some point of the respiratory tract with a gravity 
greater than in any other region on account of the 
involvement of the arytenoepiglottic folds and the 
consequent obstruction of the larynx; aphonia 
from injury to the vocal cords or to the nerves; 
emphysema, edema, penetration of blood in 
larynx, or injury of the pneumogastric or laryngeal 
nerves; dyspnea due to the same cause, plus injury 
to the phrenic; dysphagia, due to swelling or pain; 
erysipelas is a frequent complication, as is pyemia 
or sepsis; edema of the glottis is very common; 
spasmodic croup, due to pressure or to nerve injury, 
is not rare; concussion of the cervical column 
communicated to the spinal cord, to the pneumo- 
gastric, phrenic, cervical plexus, and brachial 
plexus has been observed in severe wounds. 
The symptoms of entrance of air into the veins 
are a wind-sucking or gurgling sound, immediate 
pallor of the face, dilatation of the pupil, irregular 
or tumultuous action of the heart, embarrassed 
breathing, and death. The wound should be 
plugged at once with the finger, and all the usual 
means of resuscitation vigorously and persistently 
applied. The amount of air introduced is a grave 
factor. If the wound is small, the operation may 
be continued by keeping the wound constantly 
filled with warm sterilized water. 
The sequels of the wounds of the neck are: per- 
manent aphonia or dyspnea or dysphagia, necrosis 
of the cartilages and of the hyoid bone; torticollis 
due to contraction of cicatrix, to inflammatory 
adhesions of the muscles, or to nerve injury; fistu- 
lous tracts; granulations obstructing the respira- 
tory tract. 
Deep punctured wounds striking the large vessels 
are those which are most commonly followed by 
deep and extensive extravasation and traumatic 
aneurysms; they call for the ligation of the two 
ends of the wounded vessels; it is here that a proxi- 
mal loop ligature of the main trunk, low down 
when practicable, will be of the greatest assistance 
in controlling the hemorrhage during the search 
for the bleeding ends. They are also more com- 
monly followed by emphysema than the incised 
wounds. When they involve a nerve, they may 
cause tetanus or spasmodic croup. Deep incised 
wounds are often rapidly fatal from the extensive 
hemorrhage, because it is rare that some artery or 
vein has not been .opened; the same remarks apply 
here as applied to their treatment. Deep contused 
and lacerated wounds present here no special pecu- 
liarities not covered by the foregoing descriptions 
and the description of these wounds in general. 
Gunshot wounds usually cause much hemor- 
rhage; they sometimes recover most unexpectedly; 
of course, their gravity varies with the injuries 
inflicted. When the ball is deeply seated, no dis- 
section should be made to extract it until later, if 
it produces disturbance. See Gunshot Wounds. 
Poisoned wounds-i. e., bites, stings-are more 
frequent on the neck, on account of its exposed 
condition; also more grave, because no clothing 
has protected the'parts; also because they are 
usually followed by great swelling, which, reaching 
the arytenoepiglottic folds, causes obstruction of 
the larynx. Bites of a rabid animal are more 
serious, because they have a shorter distance to 
travel to reach the central organs of innervation, 
and because no clothing has wiped the animal's 
teeth. 
Foreign bodies in wounds of the neck are com- 
mon-wadding, pieces of clothing, piece of the 
weapon or bullet, etc. 
Fractures of the neck are rare. See Spine. 
Dislocations and sprains are the result of in- 
juries in which the head is much stretched, most 
commonly and especially when violently striking 
first upon the vertex; they give rise to great pain, 
particularly when the head is thrown backward. 
The treatment consists in thorough rest of the part 
by lying on a bed or by applying a liquid glass 
bandage. 
In all injuries of the neck causing obstruction to 
the free circulation of the air, from whatever cause, 
there are great dyspnea, cyanosis, anxiety, rapid 
pulse, aphonia, dysphagia, and pain. Trache- 
otomy should be performed in such cases, and it is 
often advisable to operate before urgent symptoms 
present themselves, for death may come on NECK, INJURIES 
rapidly or suddenly before the patient can be 
reached. 
of these wounds are often much separated, and 
have a tendency to roll in on account of the action 
of the fibers of the platysma; coaptation, therefore, 
needs more care. 
Lacerated wounds are very rare. 
Gunshot wounds are also rare. Balls may 
traverse the neck without wounding any important 
structures, because the tissues are round in form, 
elastic, and movable. 
Bites by dogs are comparatively common; the 
anterior region of the neck is the favorite aim of 
dogs, especially the bulldog; they cause all the 
lesions of strangulation and of incised wounds. 
Nonpenetrating wounds-i. e., not involving the 
larynx, pharynx, esophagus, or recurrent nerves- 
are not peculiarly serious and should be treated 
as elsewhere, taking care to secure the divided ves- 
sels, etc. 
Punctured wounds, especially in duels, may pene- 
trate into the mouth, pharynx, esophagus, larynx, 
or trachea; it is important to look for such penetra- 
tions, and to keep the parts as thoroughly disin- 
fected as possible, because there is often risk of 
infection of the wound from within. The land- 
marks are the hyoid bone, the thyroid and cricoid 
cartilages. The laryngoscope should be used. 
Penetrating wounds, due to any cause involving 
the respiratory or digestive tract and the recur- 
rent nerve, are, of course, severe. 
Penetrating wounds above the larynx are less 
dangerous than those of the larynx and those 
below it; the lower the wounds, the more danger- 
ous they are. 
Wounds through the thyrohyoid membrane 
penetrate into the pharynx, injure the epiglottis, 
the arytenoepiglottic folds, the cartilages, and the 
vocal cords; they are less dangerous than below 
because they allow feeding; they are more liable 
to suppuration. 
Wounds of the larynx are comparatively fre- 
quent because of its prominence; they are usually 
very dangerous, and may be diagnosed by the 
rushing sound of the air passing through. They 
should be treated like those of the trachea. 
Wounds of the trachea are commonly followed 
by severe hemorrhage, because of the large vessels 
around it, which may also have been wounded by 
the same cause. When the severance is incom- 
plete, there is slight gaping; when the section is 
complete, the lower end is drawn in deep at each 
effort of respiration, and the soft parts cover up 
the orifice, causing suffocation. In all cases keep 
the blood and foreign substances out of the respira- 
tory tract until hemorrhage is checked. Rose's 
position may be of assistance. 
In incomplete wounds there is slight gaping, and 
the wound should not be stitched; the head should 
be flexed on the chest and fixed in that position 
by a liquid-glass bandage. 
In complete wounds, when longitudinal, there is 
little gaping. In complete transverse wounds the 
retracted lower end should be searched for and a 
strong thread passed deeply through it; an attempt 
at stitching should be made; if it fails, a tracheot- 
omy tube should be placed in it and it should be 
longer than the ordinary one, because the swelling 
NECK, INJURIES 
Peculiarities of the Injuries of the Infrahyoid 
Region. 
Burns and the effects of cold are only peculiar in 
the possibility of being followed by cicatrices 
which bind the neck and chin down to the sternum 
in a very peculiar manner. 
Contusions.-On account of the presence of the 
larynx and trachea, they may be followed by great 
concussion effects altogether out of proportion to 
the severity of the blow. Contusion of the thyroid 
cartilage by a blow upon and close to it may cause 
death without any appearance of a lesion. Con- 
tusions may cause rupture of the larynx and tra- 
chea. In hanging the compression very often bears 
upon the base of the tongue, and the larynx, with 
its vessels and nerves, is not injured. In strangu- 
lation when the traumatism is applied upon the 
larynx and the trachea, which may be torn by the 
fingers and the rope, all the structures are more or 
less torn. In some cases lesions of the skin of the 
neck, of the trachea, and of the larynx may cause 
inhibition of the heart, of the respiratory organs, 
and of the brain. 
It is especially in case of traumatism of the an- 
terior region of the neck that a complete loss of 
consciousness and a respiratory and cardiac syn- 
cope are observed. This takes place in cases of 
death through incomplete hanging, which does not 
prevent the passage of air through the respiratory 
passages. In such cases the red blood of the ar- 
teries continues red in the veins, whereas in death 
by true asphyxia the blood becomes rapidly black 
in the arteries. 
Accidental wounds are rare; the most frequent 
are punctured wounds, resulting from a fall on a 
sharp body. 
Homicidal wounds are not so rare; they are usu- 
ally incised wounds, and a cutting instrument is 
used by the criminal to make believe they are 
self-inflicted or accidental. 
Suicidal wounds are the most frequent; they 
are seldom punctured; they are usually incised 
wounds; they are most frequent at the point of 
the thyrohyoid ligament or below it; they are 
lacerated, jagged, deeper on the left side; they are 
usually directed from left to right, and obliquely 
downward or transversely across the neck; the 
large vessels are seldom injured. Usually the sui- 
cide, throwing his head back, cuts too high; the 
trachea and the rigidity of the sternomastoid pro- 
tect the vessels. If the head is bent too much, the 
larynx, the trachea, and the sternomastoid also 
protect the vessels. There is usually a single gash. 
These wounds are more commonly fatal than the 
other wounds, because the victims are usually in- 
toxicated or are laboring under delirium tremens 
or insanity. These patients should be watched 
closely, as they often tear away their dressings and 
die of hemorrhage. These wounds sometimes pre- 
sent much hemorrhage, although none of the larger 
vessels are hurt, except the anterior jugular vein; 
there are cases on record where air has penetrated 
into it and to the heart, causing death. The edges NECK, INJURIES 
NECK, INJURIES 
may lift it out of the trachea; the head should also 
be kept flexed; a moist cloth should be placed over 
the tube; the room should be warm-at about 70° 
-and a vessel with boiling water should keep the 
atmosphere moist, to avoid bronchitis and pneu- 
monia. Later, we should be mindful of the exu- 
berant granulations which may obliterate the canal. 
The sequels of wounds of the air-passages are 
permanent contractions of these passages, aphonia, 
fistulous orifices, entire occlusion of larynx, the air 
passing through the external wound. Fistulae 
are hard to cure. 
Wounds of the pharynx and esophagus are usu- 
ally through the side of the neck, by balls, knives, 
etc.; they cause much pain, spasms, hiccup, dys- 
phagia, and more or less suffocation; there is 
escape of food through the wound, if this is of a 
certain size; the thirst is great. The patient should 
be fed by enema; if the use of the esophageal tube 
becomes necessary, from insufficiency of the rectal 
alimentation, it should not be left in place, but 
introduced each time. In incised wounds stitch 
immediately; in lacerated wounds let the wound 
granulate. 
Rupture of the esophagus from contusions is 
rare; the special symptom is hematemesis. When 
the diagnosis is sure, cut down upon the injured 
spot along the anterior edge of the sternomastoid; 
stitch the wound if possible; if not, pack and let it 
granulate. 
The immediate dangers of wounds of the anterior 
region of the neck are death from hemorrhage- 
although the hemorrhage stops from syncope, it 
may start again later-from asphyxia, due to the 
tongue or epiglottis or a piece of cartilage obstruct- 
ing the passage, or to blood and clots in the larynx 
and trachea; from penetration of air in the veins. 
Penetration of the respiratory tract is recognized 
by cough, blood expectoration, hissing or boiling 
sound. 
The secondary dangers are inflammation of the 
larynx, edema of the glottis, bronchitis, pneu- 
monia, abscess and purulent dissections, emphy- 
sema, aphonia, more or less complete, and dys- 
phagia; secondary hemorrhages are common and 
serious complications. In all injuries with solution 
of continuity of the mucous membrane the most 
frequent source of death may be mediastinal em- 
physema and inhalation pneumonia. 
Wounds of the neck parallel to the longitudinal 
fibers of the muscles are more likely to be followed 
by emphysema. The remote effects and sequels 
may be exuberant granulations causing dyspnea; 
cicatrization, producing strictures of the larynx, 
trachea, and esophagus; persistent fistula; paraly- 
sis due to inflammatory thickening, which may 
disappear later, or to injury of recurrent nerves or 
the pressure of a bullet. All these complications 
should be treated here as elsewhere. 
Dislocation of the hyoid bone is very rare. There 
is one case (Gibb) in which the dislocation was 
muscular; it was accompanied by a peculiar click 
on the left side of the neck and a sensation of chok- 
ing; examination showed displacement of the left 
horn of the hyoid bone; reduction was effected by 
throwing the head backward toward the right side, 
so as to stretch the muscles of the neck, and then 
suddenly depressing the lower jaw, thus bringing 
the depressors of the hyoid bone into action. 
All the following fractures are usually due to 
violent contusions: 
Fracture of the hyoid bone is rare, but it is well 
known; the site is usually the great horn, near the 
body; it may be unilateral or bilateral; it is char- 
acterized more or less by hoarseness and dysphagia, 
according as it is without or with displacement and 
without or with deformity; accompanied by more 
severe symptoms, especially when swallowing 
fluids, which pass into the larynx because of the 
imperfect action of the epiglottis; it is reduced by 
using the fingers inside the oral cavity. 
Fractures of the larynx are less rare than frac- 
tures of the hyoid bone; they are due to great vio- 
lence; they are usually accompanied by much pain 
and suffocation, often calling for immediate reduc- 
tion or for tracheotomy. Each cartilage may be 
fractured by itself; the thyroid is most frequently 
the site; fractures without displacement are not so 
grave. Fracture of the thyroid cartilage is more 
common in old people, because of the ossification 
of the cartilage. Fracture of the cricoid is more 
dangerous than the others, perhaps because of its 
small size, which causes slight displacement to be 
followed by serious obstruction. 
Fractures or subcutaneous ruptures of the trachea 
without actual wound have been observed after 
great traumatism; they are less frequent than the 
others; they present the same symptoms and in- 
dications as the fractures of the larynx, but the 
lesions are lower down. The trachea should be 
opened below the fracture, and a long tracheotomy 
tube be introduced; when the fracture is low down, 
the lower end should be hooked, raised, and sutured 
to the skin or upper fragment. 
Spontaneous ruptures of the trachea due to 
violent efforts are admitted by some. All these 
fractures are more serious if accompanied by dis- 
placement which obstructs the air-passages. The 
symptoms are those of obstruction and shock, 
in addition to those of fractures in general; crepi- 
tation, abnormal immobility, and also aphonia, 
dysphagia, and emphysema. The fragments 
should be replaced by external and internal manip- 
ulations; if necessary, the parts should be incised 
and the fragments stitched. Tracheotomy is 
often indicated; it is well to perform the operation 
before grave symptoms develop, because these 
sometimes come on so suddenly that the patient 
may succumb before operation is possible. See 
Laryngotomy, Tracheotomy. 
Peculiarities of the Injuries of the Thyroid Body. 
Burns and freezing are on.y observed in cases of 
great and deep destruction of the neck. 
Contusions are most common in all cases of 
much violence to the neck-as has been described 
-coexisting or not with fractures of the hyoid 
bone, larynx, and trachea. The peculiar features 
they present are symptoms of cerebral congestion, 
and also the fact that they may be followed by 
myxedema. 
Wounds of the thyroid body are likely to be NECK, INJURIES 
NECK, INJURIES 
serious on account of the great vascularity of the 
organ and its friability; the bleeding is usually 
great, especially if breathing is obstructed or 
laborious. 
Punctured wounds are rare in the normal 
thyroid body, but are comparatively frequent in 
the hypertrophied organ or goiter, and, if deep, 
give rise to serious hemorrhages. 
Incised wounds are usually suicidal; those of the 
upper angles are the most frequent and the most 
serious, because of the presence of the superior 
thyroid artery; in goiters they suppurate, as a rule, 
and usually run a benign course. 
Lacerated wounds are not ordinarily followed by 
primary hemorrhage, but may present serious 
secondary hemorrhage. 
Gunshot wounds call for the same remarks; the 
thyroid gland has been carried away by a missile. 
Treatment of hemorrhage is difficult because of the 
friability which will not allow a ligature to hold 
tight enough to arrest the bleeding with safety 
against secondary hemorrhage. The same re-, 
marks apply to the forceps left in situ. Deep 
suturing succeeds best, or a chain ligature or a 
purse-string ligature. A pin or needle suture, 
such as is used for harelip, sometimes succeeds; 
pressure is not borne; it is useless to ligate the 
nearest trunk because the other vessels will keep 
up the hemorrhage; when the bleeding is serious, 
tracheotomy, if practicable, sometimes stops the 
hemorrhage by relieving its congestion; in spite 
of all, death is sometimes the result of hemorrhage. 
As regards foreign bodies in wounds, there is not 
a case on record where a bullet was found buried 
in a normal thyroid body. Poisoned wounds, 
bites, and stings are rare, except in conjunction 
with such in the infrahyoid region. 
folds, which are directly injured, are here met. 
The gaping is especially great when the head is 
thrown back; the saliva and food pass out of it 
during deglutition. Wounds of the epiglottis 
cause much suffocation, difficulty of speech, of 
deglutition, and coughing; thirst is a common 
symptom. Lacerated wounds have been observed 
in several cases of "hooking" of the chin. 
Gunshot wounds seldom penetrate posteriorly, 
because the head, being usually thrown back, the 
revolver is naturally directed upward and rests 
under the chin, which is usually carried away by 
the shot. 
Poisoned wounds, bites and stings present 
nothing peculiar. Foreign bodies in the wound 
are alimentary matter. The shock is as great as in 
all injuries to the air-passages, on account of the 
dyspnea and aphonia and dysphagia. 
Peculiarities of the Injuries of the Submaxillary 
Region (Lateral Suprahyoid or Digastric 
Triangle). 
These injuries present some peculiar interest 
because they may injure the facial or the lingual 
artery, or the hypoglossal nerve, and also because 
they may penetrate into the mouth. In regard to 
the diseases of the deep parts, it is well to state 
here at the outset, and to bear in mind, that the 
overlying lymphatic glands are more often 
affected than the tissue of the submaxillary sali- 
vary gland itself, and that practically it is im- 
material which is involved. 
Peculiarities of the Injuries of the Parotid Region. 
Wounds.-Injuries of the parotid region are 
rare; they are grave, on account of cicatricial dis- 
figurements and injuries to the facial nerve and to 
Steno's duct. Punctured superficial wounds are 
of no consequence, nor are the deeper wounds, 
unless the instrument is large and the great vessels 
are injured. Incised superficial wounds may injure 
the facial nerve and the duct, and may be followed 
by paralysis; when large, the divided nerve and 
duct should be at once stitched. Incised deep 
wounds are most serious. The diagnosis of the 
penetration of the gland rests upon the escape 
of saliva. When the wound is narrow, the hemor- 
rhage and, later, the suppuration prevent the 
diagnosis; if the pus is very liquid, it is probable 
the gland is seriously injured. To prevent fistulae 
stitch tightly and keep the jaw at rest. Deep 
wounds are more serious, because of the presence 
of the temporomaxillary vein, which becomes the 
external jugular; also of the other deep vessels. 
The bleeding is profuse and sometimes appalling; 
it should be at once stopped by plugging; then a 
provisional loop ligature should be applied on the 
common carotid close to the bifurcation; the 
bleeding points should then be ligated. If this 
fails, the source of the hemorrhage should be care- 
fully determined. If it is the external carotid, 
ligate it; if the internal carotid, ligate it separately 
or ligate the common carotid at the bifurcation 
to prevent the return through the collateral 
circulation. If the jugular vein is injured, ligate 
Peculiarities of the Injuries of the Suprahyoid or 
Submental Region. 
Burns are of peculiar importance, because the 
resulting cicatrices may draw the skin of the chin 
and of the lower lip, causing eversion of the lips and 
its consequences. 
Contusions in this region are rare, because of the 
protection of the chin. In hanging the compression 
may often bear on the base of the tongue; the ves- 
sels, nerves, and larynx are uninjured. 
Wounds of the suprahyoid region are very seldom 
homicidal, but almost always suicidal. Penetrat- 
ing wounds only are of importance; punctured 
wounds are very rare; they are only observed in the 
cases of "hooking" of the chin. Incised wounds, 
when transverse, usually gape a great deal, but 
very little when longitudinal; usually the suicide, 
throwing his head back, cuts higher than he in- 
tends in the suprahyoid region, so that the bor- 
ders of the stretched sternomastoid protect the 
vessels. The penetrating wounds open the cavity 
of the mouth, injure the tongue and epiglottis; 
there may be suffocation due to the blood or other 
foreign substances, or to the tongue or epiglottis 
falling back and occluding the larynx; there is 
usually much hemorrhage from the wounding of 
the lingual artery. More than in all injuries of the 
neck swelling and edema of the arytenoepiglottic NECK, INJURIES 
it as high up as possible, at least above the facial 
and lingual, or ligate there. After the ligation or 
ligations have been done, the accidental wound 
should be packed tightly with bits of aseptic 
sponges to prevent hemorrhage by the distal end 
of the vessels. This plugging will usually ac- 
complish this, but plugging should never be relied 
upon if the trunk has not been ligated. The 
hemorrhage is almost sure to recur, and often the 
patient thus loses so much blood that when the 
ligations are at last performed, he succumbs to 
hemorrhagic anemia. When the hemorrhages 
are unmistakably venous, the thorough systematic 
sponge-plugging may suffice, even in wounds of 
the internal jugular. Contused and lacerated 
wounds call for the same remarks, but it must be 
remembered that although the primary hemorrhage 
may not be copious, the secondary hemorrhages 
are most to be dreaded, and proper instruction 
in consequence must be given. 
Gunshot wounds suggest the same remarks, with 
the aggravation of the presence of the ball in the 
deeper structures, in the pharynx, in the bones, or 
in the brain. 
Poisoned wounds present nothing peculiar. 
point. When the wound or swelling is very low 
down, enough of the sternum must be resected to 
reach the root of the carotid and the innominate, 
and the provisional loop ligature applied there. 
Considering the gravity of a possible terrific 
hemorrhage, this advice is not too heroic. Never 
ligate the common or the internal carotid unless it 
is the wounded artery, because of the possible 
effects on the cerebral circulation. It is only when 
the persistent search for the wounded point of the 
vessel has not succeeded that the vessel itself 
should be ligated in continuity; below only, if pos- 
sible. A ligature above, whenever applicable, 
should be applied to guard against recurrent distal 
hemorrhage. We must bear in mind that arterio- 
venous aneurysm often follows punctured wounds 
which have gone through the vein and the artery. 
Wounds of the vertebral artery in this part of the 
neck are more common in the canal of the trans- 
verse process. At the base of the neck wounds of 
the vertebral artery are more grave than those of 
the carotid. 
The diagnosis of this wound will be made only 
when, upon cutting down through the extravasated 
blood, it is found that the carotid artery and the 
jugular vein are intact. When the hemorrhage-is 
profuse, it should be stopped by plugging with the 
finger or by packing, and a loop ligature should be 
applied on the subclavian or the innominate before 
proceeding further; when the wound in the verte- 
bral artery is located, it should be tied above and 
below; if necessary, the transverse process should 
be cut away with the bone-nippers. These re- 
marks apply also to the wounds of the deep cer- 
vical, the inferior thyroid, the superior thyroid, 
the lingual, and the pharyngeal arteries. 
Punctured penetrating wounds of the base of the 
neck are almost all fatal, on account of the impos- 
sibility of reaching the artery without fatal hemor- 
rhage. Punctured wounds of the nerves of the 
region (recurrent, phrenic, pneumogastric, sym- 
pathetic, spinal accessory, cervical plexus) give 
rise to the symptoms of irritation of the nerves. 
Nonpenetrating incised wounds are only serious 
if the external jugular vein has been injured, be- 
cause air may then penetrate into the veins. 
When the edges of the wounds lose their parallel- 
ism, these may form a considerable hematoma. 
Incised wounds penetrating the sternomastoid and 
severing it incompletely are not so very serious. 
Wounds dividing the sternomastoid muscle may 
result in curtailing power of the muscle from length- 
ening, due to the cicatrization. When the muscle 
has been completely severed and the head is still, 
it is sometimes brusquely thrown to the other side 
by the contraction of the intact sternomastoid. 
In case of division of the muscle from operation 
this does not take place, because the other muscles 
have gradually become accustomed, by the pres- 
ence of the tumor, to keep the head properly 
balanced. The several ends must be strongly and 
closely stitched with strong catgut, and the head 
kept in proper position by a liquid-glass bandage. 
Incised penetrating wounds of the internal jugu- 
lar are perhaps more serious than the wounds of 
the carotid, because of the danger of penetration of 
NECK, INJURIES 
Peculiarities of the Injuries of the Lateral Region 
of the Neck (Region of the Sternomastoid 
or of the Carotid). 
Burns or frost-bites present no peculiarity in the 
region of the sternomastoid, except when deep and 
reaching the sternomastoid or the underlying 
vessels and nerves. 
Contusions or blows on the neck are always 
severe, but when striking the side of the neck over 
the jugular they are particularly severe, and are 
comparatively frequent. They may cause a 
hematoma in the sheath of the muscle; they may 
cause paralysis or contracture of the muscle, pro- 
ducing a variety of torticollis; the muscle is some- 
times ruptured, also the vessels and the nerves, 
these have a train of symptoms which will be 
described further on. 
Nonpenetrating wounds-i. e., not extending 
deeper than the muscles and glands-are not seri- 
ous unless through infection. 
Penetrating punctured wounds of the neck may 
be deep without injuring the vessels and nerves, 
owing to the elasticity and mobility of the jugulo- 
carotid vessels. Penetrating wounds of the exter- 
nal jugular, of the internal jugular, and the 
carotid arteries are more serious injuries. They 
all may give rise to circumscribed or diffused 
hematoma. When this is of some size and sta- 
tionary, it must be aspirated or incised. When it 
pulsates and grows, it is because a traumatic 
aneurysm has formed, and the wounded vessel, 
vein, or artery must be ligated above and below the 
injured point. When the penetration is compara- 
tively small, the sac may be incised at once, after 
making as good a pressure above and below as 
possible. When the puncture is large, and there 
is risk of the patient bleeding much before the 
proper ligatures are secured, a provisional loop 
ligature must be applied below the wounded NECK, INJURIES 
air. When the respiration becomes embarrassed, 
the hemorrhage increases, just as in tracheotomy, 
where, as soon as the tube is introduced, the hem- 
orrhage ceases. These wounds are often due to 
tearing during the removal of tumors. Whatever 
be the cause, if the vein alone is wounded, the 
blood is black and flows continuously. The 
first thing to do is to plug the opening, to prevent 
the penetration of air; next make pressure above 
and below with the fingers, enlarge the wound, and 
fill it with boiled water to prevent the possible 
penetration of air; then look for the wounded vein 
and ligate both ends. The proximal end is the 
most dangerous, because of the penetration of air 
and of the abundance of blood coming from the 
heart. When the compressing fingers are in the 
way or if their pressure is ineffectual, a provisional 
loop ligature should be placed around the internal 
jugular until the wounded ends are ligated. 
When the wound is low down, it may be necessary 
to resect the sternum and place a provisional liga- 
ture around the innominate vein or the superior 
cava. Incised wounds of the superior thyroid, 
lingual, and facial veins close to the internal jugu- 
lar are almost as severe. 
Incised penetrating wounds of the carotids give 
rise to profuse, even terrific, hemorrhage. When 
the wound is large, or when the hemorrhage is 
moderate but does not receive prompt attention, 
it may be immediately fatal. Death from hemor- 
rhage from the carotid will thus ensue in 4 minutes, 
it is said. When the larynx or trachea is wounded, 
the blood penetrating into them causes death also 
from suffocation. The hemorrhage is sometimes 
stopped by fainting, if the wound is not too large. 
Upon reaching such a case, the first thing to be 
done is to plug the wound with the fingers or to 
pack it quickly. Packing will stop the hemor- 
rhage temporarily if the vessel is of any size above 
1/16 of an inch. It is best and safest to enlarge 
the wound and attempt to ligate the two ends in 
the wound; if this causes too much bleeding, a loop 
ligature must be applied as described. If the 
bleeding has stopped of itself, it must be borne in 
mind that it will almost surely return, and that it 
may do so when proper surgical assistance can- 
not be procured, and the patient may bleed to 
death; therefore, the case should be treated as de- 
scribed for punctured wounds. Incised penetrating 
wounds of the root of the neck are almost all fatal 
on the spot. The same remarks as above apply 
here. It is sometimes difficult to recognize which 
vessel of the neck has been divided; spurting, how- 
ever, is characteristic of arterial lesion, but the 
vein may be divided at the same time. When the 
vein and artery are simultaneously wounded, 
ligate the ends of both. In all cases when clamp- 
ing stops the bleeding and a ligature cannot well 
be substituted, the clamp should be left in place 
36 to 48 hours. 
Punctured wounds of the nerves of the region 
(recurrent, phrenic, pneumogastric, sympathetic, 
spinal accessory, cervical plexus) give rise to the 
symptoms of the irritation of those nerves. 
Incised wounds of the nerves of the region (recur- 
rent, phrenic, pneumogastric, sympathetic, spinal 
accessory, cervical plexus) are followed by the fol- 
lowing symptoms: 
When the recurrent is wounded, there is aphasia, 
more or less complete. The section of the phrenic 
and pneumogastric on one side only is accom- 
panied by respiratory and circulatory irregular 
ities; they are not necessarily fatal, but it is a most 
serious complication. Park has shown that only 
about 50 percent of these cases are fatal. Com- 
plete wounds of the sympathetic are followed by 
atresia of the pupil, slight ptosis, congestion of 
the conjunctiva, headache, congestion of the 
side of the face (unless only stimulated). It pro- 
duces mydriasis, pallor of face, and protrusion of 
eyeball. Injury of the superior laryngeal nerve is 
sometimes very serious. When possible, the 
divided ends must be sutured with fine silk. 
Penetrating or deep contused and lacerated 
wounds of the region do not expose so much to 
primary hemorrhage, but the suturing of the mus- 
cles, the ligation of the vessels, and the stitching of 
the nerves cannot be relied upon as safe, because 
of the sloughing that usually follows those wounds; 
for the same reason secondary hemmorrhages are 
much more common and more grave. Penetrat- 
ing or deep gunshot wounds of the region call for 
the same treatment, and, in addition, the fre- 
quent penetration of the digestive and respiratory 
tracts and spinal canal with their possible compli- 
cations; the presence of a ball, or foreign bodies 
deeply lodged and unremovable in these wounds, 
injures the vessels more frequently and seriously 
than the deep punctured wounds. Here, less than 
anywhere else, should search be made for the bul- 
let. When, however, the wound is larger, the fin- 
ger may be introduced, and if the ball is felt, it 
should be removed. 
Poisoned wounds, stings, bites, etc., present 
nothing peculiar in this region. 
Foreign bodies, usually bullets, may remain 
embedded in the tissues without giving rise to any 
serious trouble; a bullet may thus remain in con- 
tact with the large vessels without causing disturb- 
ance, but not so with the nerves. 
Rupture of the sternomastoid is more common 
than that of other muscles; it has taken place after 
falls, sudden twists, and violent muscular contrac- 
tions. There are great pain, a depression on the 
course of the muscle, great hematoma; the head 
is often twisted by the action of the other muscle. 
The treatment consists in placing the head in 
proper position, and immobilizing it in a liquid- 
glass bandage. The rupture is usually partial; 
when complete, the ends are far apart; it is well to 
cut down and stitch; otherwise a kind of torti- 
collis may result from the lengthening of the muscle. 
NECK, INJURIES 
Peculiarities of the Injuries of the Supraclavic- 
ular Region. 
Burns or frost-bites are rare, as the region is 
usually well protected. 
Contusions sometimes present hematomata so 
large as painfully to compress the branches of the 
brachial plexus. In fractures of the clavicle the 
brachial plexus may be injured. NECK, INJURIES 
NECK, INJURIES 
Superficial punctured wounds may open the 
external jugular, the terminal part of the external 
and anterior jugulars and of the cephalic, but they 
are seldom serious unless infected. Punctured 
wounds of the subclavian vein and artery may also 
give rise to serious hematomata. When persistent, 
they should be aspirated or incised. We should 
bear in mind that hematoma may be due to a 
wound of the vein, and that the connection may 
still exist. This will surely be the case if, after 
aspiration, it fills up again. In case of incision 
the deeper clots should not be disturbed, so as not 
to open the wound in the vein in case that lesion 
has occurred. 
Injury to the subclavian artery is recognized by 
the pulsations of the hematoma; it is then a 
traumatic aneurysm. The artery should be li- 
gated. When the swelling is moderate, the ligation 
should be made in the supraclavicular region, 
using, if necessary, an aneurysmal needle with a 
detachable point. In the majority of cases this 
simple ligation will suffice to cure the aneurysm; 
if not, compression of the axillary or its ligation 
should also be done, then the sac incised, and the 
injured points ligated above and below. When 
on the right side, the artery can only be reached 
and encircled in its second portion after dividing 
the anterior scalene; no permanent ligature should 
be applied there; a provisional loop ligature should 
be placed, the sac incised, and the injured point of 
the third portion ligated permanently above and 
below. On the left side the ligation of the second 
portion can be made permanent at once, as it is as 
safe on this side as a permanent ligature is unsafe 
on the second portion of the right side. When 
the swelling is so great as to cause failure of the 
procedure outlined, or so as to discourage even the 
attempt, but only then, a provisional ligature 
should be applied upon the first portion of the 
subclavian; the axillary should be compressed or 
treated in the same way; then the sac is incised 
and the two ends ligated. In some cases these 
ends cannot be found; packing with bits of aseptic 
sponges should then be resorted to, with com- 
pression over it. Should the hemorrhage return, 
the clavicle should be sawed through and the two 
ends secured. When the artery on the right side 
is wounded close to the scalene, so as to compel 
ligation of the second portion, this should be done 
with double catgut, without rupturing the coats, 
and with a bloodless space between the ligatures. 
On the left side the second portion can be ligated 
with safety after the old method, but the new 
method should be applied there also in preference. 
The permanent ligation of the first portion on 
either side should not be done unless it can be done 
thoroughly, with double catgut, without rupturing 
the coats, and with a bloodless space between. 
As this cannot be safely done, as a rule, without 
resecting the inner extremity of the clavicle and 
the corresponding part of the sternum, this should 
only be done when the ligation of the second por- 
tion cannot be performed satisfactorily as described. 
Arteriovenous aneurysm, due to punctured 
wounds of both the vein and artery simultane- 
ously, should not be interfered with unless they 
grow or cause serious pressure-symptoms. Then 
both the artery and the veins should be ligated 
above and below, and the sac extirpated, unless 
too adherent to surrounding structures; if left in 
place, it should be incised, to diminish its pressure 
effects; sometimes these continue, although abated. 
Punctured wounds of the nerves rarely cause 
paralysis, but may cause persistent pain, neuralgia, 
and trophic changes in the area of distribution. 
Punctured wounds of the lymphatic duct on the 
right, and of the thoracic duct on the left, may 
produce a chyloma, which should be treated as a 
venous hematoma; usually it is only then that it is 
recognized. Punctured wounds of the apex of the 
lungs may be followed by emphysema, at first 
limited and then generalized. 
Superficial incised wounds are not serious unless 
infected. Bleeding from the external and an- 
terior jugulars and of the cephalic is easily ar- 
rested; however, the wounding of these veins near 
their point of discharge into the subclavian may 
be followed by severe hemorrage and by entrance 
of air into the veins. 
Incised wounds of the third portion of the sub- 
clavian artery, when large, are followed by rapid 
death; when smaller, they often cause traumatic an- 
eurysms; the treatment is the same as indicated for 
punctured penetrating wounds. Incised wounds 
of the subclavian vein are most serious because of 
the amount of bleeding, often causing rapid death, 
and also because of the quick penetration of air 
into the vein. The vein should be at once plugged 
with the finger, or, better, an aseptic packing; then 
an attempt should be made to enlarge the wounds 
and to clamp it, then ligate the two ends. When 
this is impossible, a provisional loop ligature should 
be applied on the first portion of the vein; also 
compression should be made on the axilla and the 
two ends ligated. The ligation of the proximal end 
is to secure against hemorrhage and also against the 
entrance of air; but the ligation also of the distal 
end is, of course, indispensable. 
Incised wounds of the lymphatic duct on the 
right side and of the thoracic duct on the left are 
diagnosed by the oozing of the peculiar fluid these 
ducts contain. If possible, the distal end should 
be ligated, and this usually stops the flow, since 
there is a valve on the proximal end. There is 
seldom, if ever, any discharge from it. When 
ligation is impossible, compression will often suf- 
fice. It is very seldom that any further trouble is 
noticed, because there exist usually two or three 
branches, and the uninjured ones carry on the 
circulation. When this fails and a chyle fistula is 
established, the patient loses flesh and succumbs. 
Incised wounds of the brachial plexus are fol- 
lowed by paralysis of the affected area; they should 
be stitched at once. The lesions, from whatever 
cause, may affect only one branch. Paralysis 
never affects the interior, anterior, and posterior 
surfaces of the arm, because these are supplied by 
the anastomoses of the intercostal filaments with 
those of the internal brachial cutaneous. They 
must not be confounded with the anesthesia and 
paralysis resulting from contusions of the shoulder 
in hysteric subjects (hysterotraumatism). The NECK, INJURIES 
NEPHRITIS 
treatment is by electricity. If a callus includes a 
nerve, it must be resected. 
Incised wounds of the phrenic nerve are most 
serious. However, when the nerve has been 
pressed upon by a tumor for some time, the 
wounding of it is not so dangerous. Incised 
wounds of the apex of the lungs are not so likely 
to be followed by emphysema as the punctured 
wounds. 
Contused and lacerated wounds are much more 
serious than clean wounds, because of the impossi- 
bility of primary union, and because of greater 
liability to secondary hemorrhage. Gunshot 
wounds also are serious, for similar reasons. 
Dislocations of the head of the clavicle are a fre- 
quent cause of serious contusion of the region. 
Fractures of the clavicle sometimes cause wounds 
of the vein or of the artery or of the brachial 
plexus. Shock accompanying injuries in this 
region is sometimes very great, on account of 
the large nerves implicated. 
death follows quickly by paralysis of the dia- 
phragm. Incised wounds of muscles are usually 
due to sabre cuts; they may include almost all 
the muscles; they may reach the vertebrae, when 
the head drops forward; the hemorrhage is great. 
Incised wound of the vertebral artery give rise to 
profuse hemorrhage. The peculiarities of the 
treatment of these wounds are the need of prompt 
attention, the impossibility of ligating both ends 
of the artery if it has been wounded high up, the 
suturing of the large muscles, the difficulty of 
keeping the head steady, and to secure drainage. 
A liquid-glass bandage or a jury-mast apparatus 
will assist materially. 
Wounds of the posterior region are said to be 
followed by sexual impotency when the membranes 
of the cord are involved; also by paresis and wast- 
ing of the lower extremities and of the testicles. 
Larrey contends that these results may take 
place even when the cord is not affected. 
Gunshot wounds are usually serious if they 
reach the membranes or the cord. When pressure- 
symptoms are present, very extensive and deliber- 
ate dissections must be done to remove the ball, 
the fragments of broken lamellae, or clots or 
foreign bodies which cause the pressure. Foreign 
bodies causing pressure-symptoms on the cord 
must be removed at almost any cost. 
Ruptures of the muscles of the nucha are re- 
ported in those who carry heavy loads on the 
head; the symptoms are those of other muscular 
ruptures. Ruptures of the attachments of the 
rhomboid and of the levator anguli scapulae have 
been seen in farm-laborers. Shock accompany- 
ing injuries of the posterior region is usually great, 
being often complicated by concussion and con- 
tusion of the cord or of the cerebellum or of the 
whole brain. 
NECROSIS.-The death of cells surrounded by 
living tissues. Necrosis proper refers to death in 
mass; necrobiosis, to death of individual cells. 
Among the causes of necrosis are (1) direct injury; 
(2) obstruction of the circulation; (3) loss of trophic 
influence. The varieties of necrosis are: (1) 
Coagulative necrosis; (2) liquefactive necrosis; 
(3) cheesy necrosis; (4) dry and moist gangrene. 
See Gangrene. Necrosed tissues may be absorbed, 
retained, or thrown off. The dead tissue is called 
'sequestrum in case of bone and sphacelus in case of 
soft parts. In surgery the term necrosis is often 
applied specifically to the death of bone. See 
Bone (Diseases). 
NELAVAN.-See Sleeping Sickness. 
NEPHRECTOMY.-See Kidney (Surgery). 
NEPHRITIS (Bright's Disease; Inflammation 
of the Kidney).-Marvelously accurate as were 
Bright's descriptions of many of the forms of 
renal disease which have since received his name, 
it is clearly unreasonable to limit the name to the 
conditions literally described by him, since others, 
evidently a part of the same process, were not in- 
cluded in his descriptions, while other additions, in 
turn, had to be made to fill out these. Naturally, 
too, all are not agreed, even to-day, as to what 
should be included under the term. On the other 
hand, it would be futile to attempt to eliminate the 
Peculiarities of the Injuries of the Posterior 
Region of the Neck. 
Burns and frost-bites are only particularly im- 
portant here because of the cicatrices which may 
follow, causing disfigurement in an exposed part, 
and also possibly causing deviations of the head, 
from retraction. 
Contusions are more frequent than in front; they 
are particularly painful, because the muscles con- 
tused are those which keep the head in balance; 
they are often accompanied by fracture of the 
spinous processes and laminae, contusion and con- 
cussion of the spinal cord and even of the brain. 
Punctured wounds, nonpenetrating-i. e., not 
penetrating the vertebral artery and the spinal 
cord-are simple wounds, and seldom give rise to 
any trouble. However, should they be large punc- 
tured wounds, and strike the deep cervical artery 
or the posterior jugular veins, they may give rise to 
serious hematoma. When this persists, it should 
be aspirated or incised. When it pulsates, it is a 
traumatic aneurysm of the said artery, and should 
be treated as such. Punctured wounds of the 
vertebral artery may give rise to an aneurysm also, 
which must be treated as such-that is, by ligating 
above or below, or both, when possible, and then 
incised. Much hemorrhage must be expected from 
the untied end, and the surgeon must plug tightly 
with aspectic sponge and make firm pressure with 
a bandage. 
Punctured wounds of the spinal canal through 
the interlaminar spaces, when the head is flexed 
forcibly, or through a fracture of the laminae, 
are serious only if becoming infected. Incised 
wounds reaching the spinal cord itself are fol- 
lowed by paralysis of the parts below. If the 
wound is and remains uninfected, the cicatrization 
by primary union may take place and the paraly- 
sis disappear; if not, it will be permanent. If be- 
tween the occipital and the atlas or axis the me- 
dulla oblongata is severed, death is instantaneous. 
Infanticide is often effected by a long needle or 
pin driven between the occiput and the vertebra. 
If the lesion is above the origin of the phrenic, NEPHRITIS 
NEPHRITIS 
words "Bright's disease" from the nosology. Under 
the term will be considered: (1) Acute parenchy- 
matous or acute diffuse nephritis; (2) chronic 
parenchymatous or chronic diffuse nephritis, with 
a second or indurated stage of the latter; and (3) 
chronic interstitial nephritis. The amyloid or 
waxy kidney is not, strictly speaking, a variety 
of Bright's disease. Amyloid disease of the kidney 
occurs in two forms-first, as a part of general 
amyloid disease, shared by the kidney in common 
with the liver, spleen, and other organs; and, 
second, as amyloid infiltration of certain portions 
of kidney previously invaded by inflammation. 
See Urine (Examination). 
crementitious substances, of which urea is the 
type. Uremia possesses its own symptomatology. 
Headache and drowsiness may be initial symptoms. 
At other times sudden vomiting is the first sign. 
Not infrequently epileptoid convulsions, without 
previous warning, are the earliest manifestations; 
at all times an alarming and dangerous symptom. 
The convulsions usually alternate with periods 
of drowsiness, though sometimes also with lucid in- 
tervals. The onset of convulsions is sometimes pre- 
ceded by sudden blindness and amaurosis. Some- 
times the pulse is abnormally slow. If the condition 
does not pass away, exhaustion supervenes, and 
Cheyne-Stokes breathing may be the final symp- 
tom. Rarer symptoms of acute nephritis are 
an intense itching of the skin; shortness of breath, 
due to edema of the lungs or a feeble dilated heart; 
delusional insanity as a part of the uremic sympto- 
matology; and palsies, monoplegic or hemiplegic. 
Complications and sequels of acute nephritis are 
not numerous. They include pleurisy, pneumonia, 
bronchitis, and pulmonary edema. Hypertrophy 
of the left ventricle is a possible, but very rare, 
result. 
Diagnosis.-The diagnosis is easy. Dropsy, be- 
ginning in the face, albuminuria, blood discs, 
blood casts, and epthelial casts in the urine point 
unmistakably to acute Bright's disease. 
The peculiarity of this form of Bright's disease 
is that, in the majority of cases, the cells lining the 
uriniferous tubules are the primary seat of attack. 
As such, the cells enlarge, proliferate, and degene- 
rate, choking up the tubules and interfering with 
the proper elimination of excrementitious matters 
usually separated from the blood by the kidneys. 
Etiology.-Most cases of acute parenchymatous 
nephritis are caused by the infectious diseases, 
especially scarlet fever and diphtheria, though 
cold, and especially cold combined with moisture, 
is an acknowledged cause. 
Symptoms.-The first symptom to attract atten- 
tion is generally a puffiness about the face (see 
Face in Diagnosis), which usually extends to the 
extremities and, in extreme cases, to the trunk, 
producing in a word, general anasarca. Thus, 
attention is attracted to the urine, which often 
appears "smoky" to the naked eye, an appearance 
due to the presence of small quantities of blood in 
acid urine. The same urine, if made alkaline, 
will exhibit a brighter red hue. It contains 
albumin, commonly in large amount, and the 
microscope shows numerous blood discs, also 
blood casts, epithelial casts, and free renal epithe- 
lium. This may be regarded as the distinctive 
sediment of acute nephritis. Hyaline casts, 
which are not characteristic of any form of renal 
disease, are also present. To these are soon 
added, in all cases of prolonged duration, dark 
granular casts and dark granular cells represent- 
ing degenerated renal cells. Pus-cells and pus- 
casts are sometimes present. 
The urine of acute Bright's disease is also scanty, 
of correspondingly high specific gravity, and dis- 
posed to deposit uric acid crystals and mixed urates 
when in the fresh state. At the beginning the 
specific gravity of the urine is high. Complete sup- 
pression of urine is not infrequent. Various degrees 
of inconvenience result from the dropsy. It may 
involve the penis and scrotum, invade the serous 
cavities, especially the pleurae and peritoneum. 
Positive fever is seldom present; neither is severe 
pain in the kidney region, although it is more 
frequent in this than in any other form of Bright's 
disease. The pulse is moderately accelerated. 
Nausea and vomiting sometimes usher in the 
disease. 
The serious danger of acute Bright's disease is 
uremia, a toxic condition due to retention of ex- 
Acute Parenchymatous Nephritis. 
Acute Paren- 
chymatous 
Nephritis. 
Chronic Paren- 
chymatous 
Nephritis. 
Chronic Inter- 
stitial 
Nephritis. 
1. Most common 
1. Later life; often 
1. Later life; often 
in children, from 
the consequence 
results from alco- 
exposure or in- 
fectious fevers. 
of acute attack. 
holism, gout, 
lead-poisoning. 
2. Edema of low- 
2. In early stage 
2. Dropsy slight or 
er eyelids; then 
of upper extrem- 
ities, trunk, and, 
lastly, lower ex- 
tremities. 
same as acute 
form; later, 
dropsy may di- 
minish. 
entirely absent. 
3. Urine scanty, 
3. Urine normal or 
3. Urine greatly in- 
dark or smoky 
increased amount; 
creased; specific 
color, high spe- 
specific gravity 
gravity low, 1005; 
cific gravity, 
may fall to 1010; 
urine pale in 
1025 or over. 
urine pale. 
color. 
4. Large amount 
4. Late in attack, 
4. Albumin greatly 
of albumin. 
greatly dimin- 
ished; occasion- 
ally absent. 
diminished, often 
absent. 
5. Variety o f 
5. Large and small 
5. Hyaline or finely 
casts, such as 
granular casts ; 
granular casts, 
hyaline, blood, 
compound 
occasionally dark 
epithelial, and 
granule cells, and 
in color; infre- 
waxy casts, also 
free red blood 
globules, and 
epithelial cells. 
fatty epithelium. 
quently blood 
casts and oil 
droplets. 
6. Urea di min-, 
ished. 
6. Urea diminished. 
6. Urea diminished. 
7. Recoveries 
frequent. 
7. Recoveries rare.. 
7. Indefinite dura- 
tion, but never 
cured. 
Prognosis.-This is usually favorable if treat- 
ment is promptly instituted. Sometimes the 
disease is overlooked for a time, when it is more 
intractable. In fatal cases uremic convulsions 
often end the scene. 
Treatment.-Many cases recover without other NEPHRITIS 
NEPHRITIS 
treatment than rest in bed, warmth, and milk diet. 
These are all essential to a successful treatment. 
In severe cases dry cups, followed by fomentations, 
should be applied to the loins. In all cases brisk 
purgation should be produced, especially by the 
salines, including bitartrate of potassium and com- 
pound jalap powder. Calomel and jalap are good 
preliminary purges. Action of the skin should be 
favored by sweet spirit of niter, neutral mixture, 
warm applications and warm baths, and, if neces- 
sary, by the vapor bath. 
Having secured a free action of the bowels, 
digitalis, 5 to 20 minims of the tincture every 4 
hours, is the best diuretic, but it may be substi- 
tuted by the tincture of strophanthus in the same 
dose, or by spartein in 1/4 to 1/2 of a grain doses 
every 4 hours. When spartein cannot be obtained, 
broom tea may be used. It is an efficient but 
nauseous diuretic. Infusion of cream of tartar and 
juniper berries is at once a good diuretic and aperi- 
ent, or the cream of tartar may be used alone, 
making a drink which is pleasant when cool. 
Should uremic convulsions supervene, the most 
prompt and energetic measures must be used. 
Immediate elimination should be secured by active 
purgation by croton oil or elaterium, vapor baths, 
and, if necessary, pilocarpin should be employed 
to promote sweating. Pilocarpin hydrochlorid 
should be given hypodermically in doses of 1/12 
to 1/3 grain, according to the age of the patient. 
Its action should be favored by warm covering and 
hot applications. The convulsions should be con- 
trolled by chlorform or chloral. 
casts containing fatty renal cells. In addition are 
found free fatty renal cells, granular fatty cells 
(compound granule cells). More rarely blood- 
corpuscles are present, and in a few instances there 
is more or less constantly present blood-consti- 
tuting chronic hemorrhagic nephritis. See Ukine 
(Examination). 
There are few other distinctive symptoms. 
Edema is not always present. A peculiar waxy 
appearance of the skin often betrays the disease, 
with a yellowish tinge, as contrasted with the 
opaque white of the edema of acute Bright's dis- 
ease. Cardiac symptoms are more frequent than 
in the actue form. Hence weakness and shortness 
of breath are often symptoms. The same com- 
plications are liable to occur as in the acute form. 
There are no symptoms by which the onset of the 
stage of secondary contraction may certainly be 
recognized. Long duration of the illness is pre- 
sumptive evidence that contraction has set in, and 
when there is superadded hypertrophy of the left 
ventricle and accentuation of the aortic second 
sound, with polyuria and lowered specific gravity 
of the urine, its occurrence is rendered more likely. 
The diagnosis is usually easy. High albumin- 
uria, with dropsy and fatty casts, free fatty renal 
cells, and granular fatty cells point easily to chronic 
parenchymatous nephritis. There are, however, 
intermediate forms, when the albumin is less 
copious and the distinctive forms of casts are want- 
ing, when the distinction between chronic paren- 
chymatous nephritis and chronic interstitial 
nephritis only becomes possible by prolonged study 
of the case. 
Amyloid degeneration often invades chronic 
nephritis, but no additions are made to the symp- 
toms by which such a state of affairs can be recog- 
nized. In the purer forms of amyloid disease the 
kidney shares the process with the spleen and liver, 
and enlargement of these, associated with the 
causes of such degeneration, come to our aid in 
diagnosis. 
The prognosis is unfavorable as to cure, but if the 
cases are brought under proper management as to 
diet, habits of life, and some treatment by medi- 
cine, much can be done to prolong life. 
The treatment is, however, more difficult than in 
acute nephritis. More discrimination is required 
and results are more difficult of attainment. 
Spontaneous recovery is probably impossible. 
The indications are, first, to improve nutrition, 
restrain the accumulation of toxic matters in the 
blood, and second, to combat symptoms and com- 
plications. The first indication is fulfilled by suit- 
able food and tonics, including iron. The food 
should be easily assimilable, in which proteids are 
kept at a minimum. Milk and vegetables are the 
ideal diet, yet a moderate amount of meat, fish, 
and eggs may be permitted under ordinary cir- 
cumstances. It is rather the quantity than the 
kind which must be limited. Red meats are some- 
times disallowed, and a quantity of fish and poul- 
try permitted which far outweighs in its nitrogen a 
small piece of beefsteak. Rich milk should be 
avoided and should be diluted by water or Vichy. 
As such it should always constitute a large part of 
In this form of chronic Bright's disease, beside 
the tubal involvement, the interstitial tissue be- 
comes infiltrated with cells, which are later differ- 
entiated into fibroid tissue, resulting in more or less 
induration. The tubular involvement is still a 
conspicuous part of the process. The tubules are 
distended by proliferated and degenerated cells, 
which include fatty cells as well as cells less ad- 
vanced in degeneration. Certain white specks are 
resolvable by the microscope into coils of fattily 
degenerated tubules. Its typical macroscopic prod- 
uct is the large white kidney. An indurated form 
sometimes results, which is regarded by some as a 
further stage of the large white kidney-stage of 
secondary contraction-but probably also occurs 
as a direct result of the diffuse nephritis. 
It may be a continuation of the acute form, or it 
may originate de novo, or it may arise insidiously, 
more frequently, perhaps, favored by a vulnera- 
bility due to a previous acute parenchymatous 
nephritis. 
The symptoms include edema in various degrees, 
which in an advanced stage of the disease equals 
that described in acute nephritis. Less advanced 
stages exhibit slighter degrees of dropsy, while in 
some cases there is no edema. In many cases 
there is no dropsy in the initial stage. 
The urine is albuminous, and the quantity of 
albumin is variously large. The sediment includes 
hyaline casts, oil casts, dark granular casts, and 
Chronic Parenchymatous Nephritis. NEPHRITIS 
NEPHRITIS 
food. Rice, properly cooked, is a typical article of 
food for this form of disease. 
Milk may be taken boiled or unboiled, hot or 
cold, according to the convenience and taste of the 
patient. Raw milk is generally better digested 
than boiled milk. It should be taken regularly 
every 3 hours, in the proportion of 6 to 10 ounces 
or more, according as the total quantity in 24 
hours is to be 2 or 3 liters. 
The dose of milk should be taken slowly, in 
small swallows, so that the clots formed in the 
stomach may be as small as possible. For cow's 
milk, which is generally employed, we may, as 
required in individual cases, substitute, in whole 
or in part, the milk of the goat or the ass, also 
kefir or koumiss. If the taste of milk is very 
repugnant to the patient, it may be flavored with 
orange-water or some other agreeable flavor. It is 
unnecessary to employ for this purpose brandy or 
other alcoholic liquors. All the efforts of the 
physician should be directed to making the patient 
and his friends understand that milk is the essential 
basis of the treatment. 
Iron, quinin, and strychnin are excellent tonics, 
yet iron is too often indiscriminately given, and 
sometimes more harm is done with it than good by 
locking up secretions, causing headache and con- 
stipation. Large.doses should be avoided. A few 
drops of the tincture of the chlorid of iron and a 
dram or two of Basham's mixture should suffice 
for a dose. Rest, bathing, and massage are advis- 
able hygienic measures. The clothing should 
always include wool next the skin in winter and 
summer. Elimination by the skin is facilitated by 
such clothing. The urine should be tested by fre- 
quent analysis, and if the quantity of^urea elimi- 
nated is small compared with that ingested, its 
excretion should be stimulated by warm baths, 
warm packs, or vapor baths. The urine elimina- 
tion should be aided by aperient remedies, in- 
cluding salines. Edema is to be treated by the 
same measures as acute nephritis. Sometimes it 
is very helpful to scarify the legs. Enormous 
quantities of fluid are thus liberated, with great 
refief to the patient. Uremia should be treated as 
described under acute nephritis. 
of urine, or by the ophthalmologist in the eye clinic, 
when least suspected by the patient-an examina- 
tion suggested by a dimness of vision or more or 
less blindness. As often the discovery of hyper- 
trophy of the left ventricle without explainable 
cause leads to an examination of the urine, and the 
discovery of a small amount of albumin and a few 
casts. More rarely a sudden outburst of uremic 
convulsions is the first intimation of the presence 
of the disease, and may also be the concluding 
symptom. Headache is a frequent symptom, 
with unpleasant throbbing in the temples. Occip- 
ital headache is said to be especially characteristic, 
but this symptom occurs under so many conditions 
that it can scarcely be allowed any diagnostic value. 
Never, except sometimes toward the close of the 
disease, is there dropsy in a marked degree, though 
at times a tightness of the shoe or a swelling about 
the ankle toward evening first attracts the atten- 
tion of the patient. 
The changes in the urine are more or less charac- 
teristic. The quantity is always copious; its 
specific gravity is low, and in it are found usually 
only a few hyaline casts, occasionally containing 
an oil drop or two. Casts are often not found, 
though less frequently with the use of the centri- 
fuge. Albumin is sometimes totally absent, and 
there is a prealbuminuric stage, rarely recognized, 
in which there is neither albumin nor casts. See 
Urine (Examination). 
Arterial sclerosis, recognizable commonly only 
in the radials, sometimes in the temporals, is more 
or less characteristic. Its exact relation to the 
renal disease is perhaps not precisely determined. 
Sometimes found early, and even preceding other 
symptoms, it may then be regarded as a cause. 
At others, occurring later, it is perhaps a conse- 
quence. The changes are chiefly in the intima and 
media, inflammatory and degenerative rather than 
hypertrophic in the muscular coat, as once sup- 
posed. 
The diagnosis is commonly easy. The absence 
of dropsy, small amount of albumin, few hyaline 
casts, hypertrophy of the left ventricle, and al- 
buminuric retinitis point rarely to anything else 
except the contracted kidney. Only in those cases 
of chronic parenchymatous nephritis referred to in 
the stage of secondary contraction or in the unde- 
terminate and imperfectly developed first stage 
is there sometimes difficulty, which time and a 
careful study will remove. 
The prognosis of contracted kidney is unfavor- 
able as to recovery. No kidney in which the 
characteristic interstitial change has been wrought 
probably ever returns to its normal state. 
Something may be done to arrest further develop- 
ment of the disease, so far as it is- possible to 
counteract the causes which favor its spread. 
Sooner or later the disease advances slowly or 
rapidly to an ultimate unfavorable termination. 
Treatment.-As has been intimated, treatment 
must consist mainly in measures calculated to 
arrest the spread of the disease from localized foci 
in the kidney to larger areas. The uric acid of the 
gouty diathesis must be kept in solution or elim- 
inated, lead must be dissolved out of the blood, 
Chronic Interstitial Nephritis (Contracted Kidney). 
In this form of Bright's disease the resultant is a 
small kidney in which the interstitial connective 
tissue predominates, but whether this is the result 
of a primary overgrowth of connective tissue at the 
expense of the tubular structure, or whether the 
latter slowly disintegrates to be as gradually re- 
placed by fibroid tissue, is a question more un- 
settled of late than it formerly was. 
The cause often cannot be traced. Overfeed- 
ing, gout, lead, alcohol, and syphilis cause a certain 
number of cases. Grief and anxiety have been 
assigned to rather an undue portion of responsi- 
bility by some authors. Hereditary influence 
must be admitted. Arteriosclerosis is a cause and 
a consequence. 
Symptoms.-The characteristic of its symptomat- 
ology is insidiousness of onset. Often the disease 
is discovered accidentally in a routine examination NEPHRITIS OF PREGNANCY 
NEPHRITIS OF PREGNANCY 
alcohol and excessive eating, especially of proteid 
foods, must be cut down, and the patient put upon 
a diet of milk, vegetables, and fruits. High 
arterial pressure should be reduced by full doses of 
nitroglycerin and aconite. If uremia threatens, 
milk and Vichy or milk and water should be given 
in lieu of all other nourishment for a time. The 
bowels should at all times be kept free, and medi- 
cines calculated to lock up secretions, such as iron 
and other astringents, should be avoided. The 
occasional use of mercurial aperients is helpful, and 
the free ingestion of liquids between meals should 
be encouraged. Diuretics are not indicated in 
the earlier stages so long as the secretion is free. 
The same hygienic measures described as necessary 
in chronic parenchymatous nephritis are essential 
in this form of disease. The treatment of uremia 
is identical with that described under acute and 
chronic parenchymatous nephritis. 
Drugs are not likely to be serviceable in clearing 
away the interstitial overgrowth. Theoretically, 
iodin and mercury should do this, but biniodid and 
bichlorid of mercury in suitable doses have been 
given for months without result. The gold prep- 
arations are not recommended. There are, how- 
ever, men of experience who claim to have had 
good results from all of these remedies, and there 
is no reason why their use should not be con- 
tinued until their true value is determined. The 
use of opium in interstitial nephritis, especially 
for the control of uremic convulsions, is danger- 
ous, and likely to prolong the condition it is 
purposed to relieve. 
matory condition in which the kidney becomes 
anemic and the epithelial cells become infiltrated 
with fat. 
The cause is probably some condition which in- 
terferes with the blood supply to the kidney, such 
as compression of the kidney by the gravid uterus, 
spasmodic contraction of the renal arteries, and an 
exaggerated hydremia of pregnancy. 
The symptoms usually manifest themselves 
during the latter months of pregnancy. These are 
albuminuria, more or less pronounced, and proba- 
bly some hyaline and granular casts. Desqua- 
mated epithelial cells filled with fat may also be 
found. The condition becomes more marked as 
pregnancy advances, and it not infrequently ter- 
minates in an outbreak of eclampsia. It disap- 
pears spontaneously after labor. 
Nephritis may manifest itself as an acute or 
chronic condition, the latter being the more com- 
mon. 
The symptoms are the same as in uncomplicated 
Bright's disease. 
The differential diagnosis between chronic 
nephritis and the kidney of pregnancy may be de- 
termined by the following: 
Chronic Nephritis. 
1. There may be a his- 
tory of previous 
kidney disturb- 
ance. 
2. There may be albu- 
minuric retinitis. 
3. Symptoms appear in 
the first half of preg- 
nancy. 
4. Casts are usually pres- 
ent in large num- 
ber-hyaline, gran- 
ular, waxy, and 
fatty. 
5. Symptoms persist 
after delivery. 
Nephritis of Preg- 
nancy. 
1. There is no such his- 
tory. 
2. There is no albumin- 
uric retinitis. 
3. Symptoms appear in 
the latter half of 
pregnancy. 
4. Hyaline and granu- 
lar casts may ap- 
pear, but are usu- 
ally few in number. 
5. Symptoms disap- 
pear after delivery. 
Amyloid Disease. 
There are two ways in which amyloid disease 
may invade the kidneys: first, as a complication of 
chronic diffuse nephritis; and, second, as a part of 
general amyloid disease when the kidneys share the 
process with the spleen, liver and other organs of 
the body. The first is not recognizable by any 
means at our disposal; the second may be inferred 
from the presence of the causes of amyloid disease: 
viz., syphilis, suppuration, and exhausting drains on 
the system, along with enlargement of the liver and 
spleen, albuminuria, and casts. The so-called 
waxy cast is probably more frequent in this form 
of chronic disease, but is not peculiar to it, or even 
to chronic disease at all, as it is found also in acute 
nephritis. In addition to these, the other varieties 
of casts more or less characteristic of chronic 
nephritis are also found: viz., oil casts, dark granu- 
lar casts, and fatty renal cells. The albuminuria is 
not commonly so large as in the typical forms of 
chronic parenchymatous nephritis. 
The treatment of the first of these forms is that 
of chronic parenchymatous nephritis; of the 
second, that of the condition causing the amyloid 
disease, aided by the tonic and restorative meas- 
ures needed in the treatment of chronic parenchy- 
matous nephritis. 
NEPHRITIS OF PREGNANCY.-Kidney in- 
sufficiency occurs in about 6 percent of all pregnant 
women, and is the result of the kidney of preg- 
nancy, or true nephritis. 
The kidney of pregnancy is a peculiar noninflam- 
The prognosis is grave; eclampsia may occur at 
any time. 
The treatment of kidney insufficiency during 
pregnancy should be prophylactic and curative. 
Every pregnant woman's urine should be regu- 
larly examined: during the first 6 months, once 
every 3 weeks; later, once every week or 10 days. 
Should albumin appear, daily quantitative ex- 
aminations should be made. This is most con- 
veniently done by the use of an Esbach's albu- 
minometer. If the amount of albumin is slight, if 
there are no casts, and if there are no general 
symptoms, such as edema; dietetic and hygienic 
treatment is sufficient. 
The patient should avoid exposure to cold and 
wet; the skin should be kept active by frequent 
bathing, followed by brisk rubbing; the bowels 
should be moved at least once daily; and the diet 
should be light and easily digested. No meat 
should be allowed. Milk, milk-broths, and the 
lighter vegetables are appropriate. Should the 
albumin increase in amount; should casts appear NEPHRECTOMY 
NERVES 
in abundance; and should there be edema of the 
face or extremities, thorough and active treatment 
is indicated. The patient should be confined to 
bed; the diet should be exclusively milk; the bowels 
should be moved 2 to 4 times daily by the use of 
salines; and diaphoresis should be encouraged by 
the use of hot baths. Diuretics are indicated, such 
as digitalis, caffein, strophanthus, and Basham's 
mixture. If, in spite of this treatment, the 
symptoms become progressively worse, the in- 
duction of abortion or premature labor is indicated. 
This is particularly urged if there are serious eye 
symptoms, or if there is persistent headache, since 
they are the premonitory symptoms of eclampsia. 
See Eclampsia. 
NEPHRECTOMY.-See Kidney (Surgery). 
NEPHROLITHIASIS.-See Kidney (Stone). 
NEPHROLITHOTOMY.-SeeKiDNEY (Surgery). 
NEPHRORRHAPHY.-See Kidney (Surgery). 
NEPHROTOMY.-See Kidney (Surgery). 
NERVES, TABLE OF PRINCIPAL. 
Name. 
Function. 
Origin. 
- 
Distribution. 
Branches. 
Abducens (sixth 
cranial). 
Motion 
Fourth ventricle 
External rectus of eye.. . . 
Filaments. 
Alveolar 
Sensation 
Inferior dental 
Molar and bicuspid teeth, 
and adjacent gums. 
Gingivales. 
Articular 
Trophic, sensory (?).... 
Anterior crural 
Knee-joint 
Capsular, synovial. 
Articular, 2 
Trophic, sensory (?).. . . 
Ulnar 
Elbow-joint 
Filaments. 
Articular, recurrent... 
Motion 
External popliteal.. .. 
Knee-joint and anterior 
tibial muscle. 
Filaments. 
Auditory (eighth 
cranial). 
Hearing 
Restiform body 
Internal ear 
Vestibular, cochlear. 
Auricular {posterior).. 
Motion 
Facial 
Retrahens aurem, attol- 
lens aurem, occipito- 
frontalis. 
Auricular, occipital. 
Auricularis magnus. . 
Sensation 
Cervical p 1 e x u s, 2d 
and 3d cervical. 
Parotid gland, face, ear... 
Facial, mastoid and au- 
ricular. 
Auriculotemporal.. .. 
Sensation 
Inferior maxillary.... 
Pinna and temple 
Articular, two branches 
to meatus, parotid, 
anterior auricular, 
superficial temporal. 
Buccal 
Motion 
Facial 
Buccinator and orbicularis 
oris muscles. 
Filaments. 
Buccal, long 
Sensation, motion (?)... 
Inferior maxillary.... 
Cheek 
Superior and inferior 
buccinator and e x - 
ternal pterygoid. 
Calcanean, internal. . 
Sensation 
Posterior tibial 
Fascia and integument of 
heel and sole. 
Several small filaments. 
Cardiac (cervical and 
thoracic). 
Inhibition 
Vagus 
Heart..... 
Branches to cardiac 
plexuses. 
Cavernous 
Sensation '.. 
Prostatic plexus 
Erectile structures of 
penis. 
Filaments. 
Cervical, eight 
Motion and sensation... 
Cord 
Trunk and upper ex- 
tremities. 
Ventral and dorsal divi- 
sions. See Plexus. 
Cervical, 1st (anterior 
division). 
Motion and sensation... 
Cord 
Rectus lateralis and two 
anterior recti. 
Filaments and communi- 
cating to vagus, hypo- 
glossal, sympathetic. 
Cervical, 1st (pos- 
terior division). 
Motion and sensation... 
Cord 
Recti, obliqui, complexus. 
Communicating and cu- 
taneous filaments. 
Cervical, 2d (ante- 
rior division). 
Motion and sensation... 
Cord 
Communicating 
Ascending, descending, 
communicating and fila- 
ments. 
Cervical, 2d (poste- 
rior division). 
Motion and sensation... 
Cord 
Obliquus inferior, scalp, 
ear, complexus, splenius, 
trachelomastoid. 
Internal or occipitalis 
major, and external. 
Cervical, 3d (anterior 
division). 
Motion and sensation... 
Cord 
Communicating 
Ascending, descending, 
and communicating 
filaments NERVES 
NERVES 
NERVES, TABLE OF PRINCIPAL. 
Name 
Function. 
Origin. 
Distribution. 
Branches. 
Cervical, 3d (poste- 
rior division). 
Motion and sensation... 
Cord 
Occiput, splenius, com- 
plexus. 
Internal, external, and 
filaments. 
Cervical, 4th (ante- 
rior division). 
Motion and sensation... 
Cord 
Shoulder and communi- 
cating. 
Comm u n i c a t i n g fila- 
ments, muscular, etc. 
Cervicals, 5th to 8th 
(anterior divisions). 
Motion and sensation... 
Cord 
Brachial plexus 
Communicating. 
Cervicals, 4th to 8th 
(posterior divisions) 
Motion and sensation... 
Cord 
Muscles and skin of neck.. 
Internal and external 
branches. 
Cervicofacial 
Motion 
Facial 
Lower part of face and 
part of neck. 
Buccal, supramaxillary, 
, inframaxillary. 
Chorda tympani 
Motion 
Facial 
Tongue, tympanum, sub- 
maxillary gland. 
Filaments. 
• 
Ciliary 
Sensation, nutrition, 
motion. 
Ciliary ganglion 
Eyeball 
♦ 
Filaments. 
Circumflex 
Motion and sensation... 
Brachial plexus 
Teres minor, deltoid and 
skin. 
Anterior, posterior and 
articular. 
Coccygeal.. 
Motion 
Coccygeal plexus 
Coccygeus and gluteus 
maximus. 
Filaments. 
Colli, superficialis.... 
Sensation 
Cervical plexus 
Platysma myoides and 
ventrolateral parts of 
neck. 
Ascending and descend- 
ing branches, filaments 
Communicans hypo- 
glossi. 
See Communicans noni. 
Communicans noni... 
Motion and sensation... 
Second cervical, third 
cervical. 
Descendens noni, depres- 
sor muscles of hyoid 
bone. 
Omohyoid and filament, 
ansa hypoglossi. 
Communicating 
Motion and sensation... 
Cervical plexus 
Spinal accessory 
Branches. 
Communicating 
Sensation and motion... 
First and second cer- 
vical. 
Vagus, hypoglossal, sym- 
pathetic. 
Three branches and fila- 
ments. 
Crural 
Sensation 
Genitocrural 
Skin, upper and central 
part ant. aspect of thigh. 
Filaments. 
Crural, anterior 
Motion and sensation... 
Lumbar plexus, sec- 
ond, third and fourth 
lumbar nerves. 
Thigh 
Middle and internal cuta- 
neous, long saphenous, 
muscular, articular. 
Cutaneous 
Sensation 
Musculospiral 
Skin of arm, radial side of 
forearm. 
One internal, two ex- 
ternal. 
Cutaneous 
Sensation 
Ulnar 
Wrist and palm 
1st and palmar cutane- 
ous. 
Cutaneous (dorsal)... 
Sensation 
Ulnar 
Little and ring fingers 
Filaments and commu- 
nicating branches. 
Cutaneous (external) 
Sensation 
2d and 3d lumbar.... 
Skin of thigh 
Anterior, posterior. 
Cutaneous (internal) 
Sensation 
Brachial plexus 
Forearm 
Anterior and posterior 
branches and filaments. 
Cutaneous (lesser in- 
ternal) (of Wrisberg) 
Sensation 
Brachial plexus 
Inner side of arm 
Filaments. 
Cutaneous (middle 
and internal). 
Sensation. Motion (?).. 
Anterior crural 
Thigh and communicat- 
ing. 
Communicating and fila- 
ments. 
Cutaneous, perforat- 
ing. 
Sensation 
Fourth sacral 
Integument covering glu- 
teus maximus. 
Filaments. 
Dental (inferior or 
mandibular). 
Sensation 
Inferior maxillary.... 
Teeth, muscles 
Mylohyoid, incisor, men- 
tal, dental. 
Dental, superior 
See Dentals (posterior and 
anterior). NERVES 
NERVES 
NERVES, TABLE OF PRINCIPAL. 
Name. 
Function. 
Origin. 
Distribution. 
Branches. 
Dentals (post, and 
ant.). 
Sensation 
Superior maxillary... 
Teeth 
Filaments. 
Descendens hypo- 
glossi. 
Motor 
Cervical plexus 
Omohyoid, sternohyoid, 
sternothyroid, thyrohy- 
oid, geniohyoid, hyo- 
glossus and muscles of 
tongue 
Muscular, tongue. 
Descendens noni 
See Descendens hypo- 
glossi. 
Digastric 
Motion 
Facial 
Posterior belly of digastric. 
Filaments. 
Dorsal, 12 (anterior 
and posterior divi- 
sions). 
Motion and sensation... 
Cord 
Muscles and skin of chest 
and trunk. 
External, internal, cuta* 
neous. 
Dorsal (of clitoris)... 
Homologue of dorsal of 
penis 
Filaments. 
Dorsal (of penis) 
Sensation 
Pudic 
Penis... ^ 
Filaments. 
Facial (seventh cran- 
ial, portio dura). 
Motion 
Floor of fourth ven- 
tricle. 
Face, ear, palate, tongue.. 
Petrosals, tympanic, 
chorda tympani, com- 
municating, post, auric- 
ular, digastric, stylo- 
hyoid, lingual, tem- 
poral, malar, infra- 
orbital, buccal, superior 
and inferior maxillary. 
Frontal 
Sensation 
Ophthalmic 
Forehead and eyelids 
Supraorbital, supratro- 
chlear. 
Genital 
Motion and sensation... 
Genitocrural 
Cremaster muscle 
Filaments. 
Genitocrural 
Motion and sensation... 
First and second lum- 
bar. 
Cremaster and thigh 
Genital, crural, commu- 
nicating. 
Glossopharyngeal 
(ninth cranial). 
Sensation and taste 
Fourth ventricle 
Tongue, middle ear, ton- 
sils, pharynx, meninges. 
Tympanic, carotid, 
pharyngeal, muscular, 
tonsillar, lingual. 
Gluteal (inferior).... 
Motion 
Sacral plexus (2d and 
3d sacral nerves). 
Gluteus maximus 
Filaments. 
Gluteal (superior).... 
Motion 
Sacral plexus 
Glutei, tensor vaginae fem. 
Filaments. 
Gustatory 
See Lingual. 
Hemorrhoidal (in- 
ferior). 
Sensation and motion... 
Pudic 
External sphincter ani, 
and adjacent integument. 
Filaments. 
Hypogastric 
Sensation 
Iliohypogastric 
Skin about external ab- 
dominal ring. 
Filaments. 
Hypoglossal (twelfth 
cranial). 
Motion 
Floor of fourth ven- 
tricle. 
Hyoglossus and hyoid 
muscles. 
Descendens noni or hypo- 
glossi, muscular, thyro- 
hyoid, geniohyoid and 
meningeal. 
Iliac 
Sensation 
Iliohypogastric 
Integument covering fore 
part of gluteal region. 
Filaments. 
Iliac 
Sensation 
Last dorsal 
Integument covering fore 
part of gluteal region. 
Filaments. 
Iliohypogastric 
Motion and sensation... 
First lumbar 
Abdominal and gluteal 
regions. 
Iliac, hypogastric, com- 
municating. 
Ilioinguinal 
Motion and sensation... 
First lumbar 
Inguinal region and scro- 
tum. 
Muscular, cutaneous and 
communicating. 
Inframaxillary 
Motion . 
Facial 
Platysma myoides 
Filaments. 
Infraorbital 
Sensation and motion .. 
Facial 
Nose and lip 
Palpebral, nasal, labial. NERVES 
NERVES 
NERVES, TABLE OF PRINCIPAL. 
Name. 
Function. 
Origin. 
Distribution. 
Branches. 
Infratrochlear 
Sensation 
Nasal 
Skin and conjunctiva of 
inner part of eye, lacri- 
mal sac. 
Filaments. 
Intercostal 
Motion and sensation... 
Spinal cord 
Muscles and integument 
of thorax. 
Muscular, anterior and 
lateral cutaneous. 
Intercostohumeral ... 
Sensation 
Second intercostal.... 
Integument of upper two- 
thirds of inner and pos- 
terior part of arm. 
Filaments. 
Interosseous (ante- 
rior) . 
Motion 
Median 
Deep muscles of forearm.. 
Filaments. 
Interosseous (poste- 
rior) . 
Motion and sensation... 
Musculospiral 
Carpus and radial and pos- 
terior brachial regions. 
Filaments. 
Labial 
Motion and sensation... 
Superior maxillary. .. 
Muscles and mucous mem- 
brane of lips. 
Filaments. 
Lacrimal 
Sensation 
Ophthalmic 
Gland and conjunctiva.... 
Filaments. 
Laryngeal (recurrent 
or inferior). 
Motion 
Vagus 
Larynx 
Branches to all laryngeal 
mus. except cricothy- 
roid. 
Laryngeal (superior) 
Sensation and motion... 
Vagus 
Larynx 
Externa 1- cricothyroid 
muscle and thyroid 
gland. Internal-mu- 
cous membrane of lar- 
ynx. 
Lingual 
Motion and sensation... 
Facial 
Mucous membrane of ton- 
gue, palatoglossus and 
styloglossus muscles. 
Filaments. 
Lingual 
Sensation 
Glossopharyngeal.... 
Circumvallate papilla; and 
glands of tongue. 
Filaments. 
Lingual 
Taste and sensation.... 
Inferior maxillary.... 
Tongue and mouth 
Filaments. 
Lumbar (5) 
Motion and sensation... 
Cord 
Lumbar and genital tis- 
sues. 
Anterior and posterior 
divisions, lumbar plex- 
us. 
Malar 
Motion 
Facial 
Lower part of orbicularis 
palpebrarum, and eyelids. 
Filaments. 
Malar 
Sensation 
Orbital 
Skin over malar bone 
Filaments. 
Mandibular 
See Maxillary, inferior. 
Masseteric 
Motor 
Inferior maxillary... • 
Masseter muscle (and tem- 
poral?). 
Filaments. 
Maxillary (inferior).. 
Sensation, motion, and 
taste. 
Trigeminus 
Muscles of mastication, 
ear, cheek, tongue, teeth. 
Masseteric, auriculotem- 
poral, buccal, gusta- 
tory, inferior dental. 
Maxillary (superior). 
Sensation 
Trigeminus 
Cheek, face, teeth 
Orbital, sphenopalatine, 
dentals, infraorbital. 
Median 
Motion and sensation... 
Brachial plexus 
Pronator radii teres, 
flexors, two lumbricales, 
fingers, palms. 
Muscular, anterior inter- 
osseous, palmar cuta- 
neous. 
Meningeal 
Sensation 
Glossopharyngeal .... 
Pia and arachnoid 
Filaments. 
Meningeal 
Sensation 
Hypoglossal 
Dura mater 
Filaments. 
Meningeal 
Sensation 
Vagus 
Dura around lateral sinus. 
Filaments. 
Meningeal, recurrent. 
Sensation 
Inferior maxillary.... 
Dura and mastoid cells.... 
Filaments. 
Mental 
Motion and sensation. .. 
Inferior maxillary... • 
Mucous membrane of 
lower lip and chin. 
Filaments. NERVES 
NERVES 
NERVES, TABLE OF PRINCIPAL. 
Name. 
Function. 
Origin. 
Distribution. 
Branches. 
Motor oculi (third 
cranial). 
1 
Motion 
Floor of aqueduct of 
Sylvius. 
All muscles of the eye, ex- 
cept external rectus, su- 
perior oblique, and orbic- 
ularis palpebrarum. 
Filaments. 
Muscular 
Motion and Sensation. . 
First and second cer- 
vical. 
Rec. cap. lat., rec., ante- 
rior major et minor. 
Filaments. 
Muscular 
Motion and sensation... 
Cervical plexus....... 
Sternomastoid, lev. ang. 
scap., seal, med., trapez. 
Filaments. 
Muscular 
Motion 
Brachial plexus 
Longus colli, scaleni, 
rhomboidei, subclavius. 
Filaments. 
Muscular 
Motion 
Musculospiral 
Triceps, anconeus, sup- 
inat. long., extens. carpi 
rad. long., brach. antic. 
Internal, posterior, ex- 
ternal. 
Muscular 
Motion.... •. 
Median 
Superficial muscles of fore- 
arm. 
Filaments. 
Muscular 
Motion 
Ulnar 
Flexor carpi ulnaris, flexor 
profundus digitorum. 
Two branches. 
Muscular 
Motion 
Great sciatic 
Biceps, semimembranosus, 
semitendinosus, adduc- 
tor magnus. 
Filaments. 
Muscular 
Motion 
Sacral plexus 
Pyriformis, obturator int., 
gemelli, quad, femoris. 
Filaments. 
Muscular 
Motion 
Anterior crural 
Pectineus and muscles of 
thigh. 
Filaments. 
Musculocutaneous ... 
Motion and sensation... 
Brachial plexus...... 
Coracobrach., biceps, 
brach. anticus, forearm. 
Anterior and posterior. 
Musculocutaneous ... 
Motion and sensation... 
External popliteal.... 
Muscles of fibular side of 
leg, skin of dorsum of foot. 
Internal, external. 
Musculospiral 
Motion and sensation... 
Brachial plexus 
Back of arm and forearm, 
skin of back of hand. 
Musculocutaneous, ra- 
dial, posterior interos- 
seous. 
Mylohyoid 
Motion 
Inferior maxillary.... 
Mylohyoid and digastric 
muscles. 
Filaments. 
Nasal 
Sensation 
Dental, anterior 
Mucous membrane of in- 
ferior meatus. 
Filaments. 
Nasal 
Sensation 
Maxillary, superior... 
Integument of lateral as- 
pect of nose. 
Filaments. 
Nasal 
Sensation 
Ophthalmic 
Iris, ciliary ganglion, nose. 
Ganglionic, ciliary, infra- 
trochlear. 
Obturator 
Motion and sensation... 
Lumbar plexus, third 
and fourth nerves. 
Obturator externus, ad- 
ductors, joint and skin. 
Ant. and post, articu- 
lating and communi- 
cating. 
Obturator (a c c e s- 
sory). 
Motion and sensation... 
Lumbar plexus 
Pectineus and hip-joint .. 
Filaments. 
Occipital, smallest or 
3d. 
Sensation 
Third cervical 
Integument of occiput... . 
Filaments. 
Occipitalis, lesser or 
minor. 
Sensation 
Second cervical 
Occipitofrontalis, ear, etc. 
Communicating, auricu- 
lar, filaments. 
Occipitalis magnus... 
Motion and sensation... 
Second cervical 
Complexus, trap, and 
scalp. 
Filaments. 
Oculomotor 
See Motor ocul . 
Olfactory (first cra- 
nial). 
Smell 
Frontal lobe, optic , 
thalamus and insula. 
Schneiderian membrane 
of nose. 
Twenty branches. 
Ophthalmic 
Sensation 
Trigeminus 1 
Forehead, eyes, nose 
Frontal, lacrimal, nasal. NERVES 
NERVES 
NERVES, TABLE OF PRINCIPAL. 
Name. 
Function. 
Origin. 
Distribution. 
Branches. 
Optic (second cra- 
nial). 
Sight 
Cortical center in oc- 
cipital lobe. 
Retina 
None. 
Orbital 
Sensation 
Superior maxillary... 
Temple and cheek 
Temporal and malar. 
Palmar cutaneous.... 
Sensation 
Median 
Thumb and palm 
Outer and inner. 
Palmar (deep) 
Motion 
Ulnar 
Little finger, dorsal and 
palmar interosseous, two 
inner lumbricales, ab- 
ductor pollicis. 
Filaments. 
Palmar (superficial).. 
Sensation and motion... 
Ulnar 
Palmaris brevis, inner 
side of hand and little 
finger. 
Filaments and two digi- 
tal branches. 
Palpebral 
Motor 
Superior maxillary. .. 
Integument of lower lid.. . 
Filaments. 
Parotid 
Sensation 
Auriculotemporal .... 
Parotid gland 
Filaments. 
Patheticus (4th cra- 
nial). 
Motion 
Valve of Vieussens... 
Superior oblique of eye... 
None. 
Pectineus 
Motion 
Anterior crural 
Pectineus muscle 
Filaments. 
Perineal 
Motion and sensation... 
Pudic *... 
Perineum, genitalia and 
skin of perineal reigon. 
Cutaneous and muscu- 
lar. 
Perineal 
Motion and sensation... 
Fourth sacral 
External sphincter ani 
and integument of anus. 
Filaments. 
Peroneal communi- 
cating. 
Sensation 
External popliteal.... 
Connecting external pop- 
liteal with short saph- 
enous. 
None. 
Phrenic 
Motion and sensation.. 
Third, fourth, and 
fifth cervical. 
Diaphram, pericardium, 
pleura. 
Filaments. 
Plantar (external).. . 
Motion and sensation... 
Posterior tibial 
Little toe and deep mus- 
cles of foot. 
Superficial and deep. 
Plantar (internal).... 
Sensation and motion... 
Posterior tibial 
Sole of foot, adduct, pol- 
lic., flexor brev. dig., toes. 
Cutaneous, muscular, 
articular, digital. 
Pneumogastric (tenth 
cranial ("par va- 
gum"). 
Sensation and motion... 
Floor of fourth ven- 
tricle. 
Ear, pharynx, larynx, 
heart, lungs, esophagus, 
stomach. 
Auricular, pharyngeal, 
superior and inferior 
laryngeal, re current 
laryngeal, cardiac, pul- 
monary, esophageal, 
gastric, hepatic, com- 
municating, meningeal. 
Popliteal (external).. 
Sensation and motion... 
Great sciatic 
Extensors of foot, skin, 
and fascia. 
Anterior tibial, musculo- 
cutaneous, articular, cu- 
taneous. 
Popliteal (internal)... 
Motion and sensation... 
Great sciatic 
Knee, gastrocnemius, tibi- 
alis posticus, plantaris, 
soleus, popliteus, skin of 
foot. 
Articular, muscular, cu- 
taneous, external 
saphenous, plantar, 
external or short 
saphenous. 
Pudendal, long (nerve 
of Soemmering). 
Sensation 
Small sciatic 
Integument of genitalia 
and inner and proximal 
part of thigh. 
Filaments. 
Pudic 
Motion and sensation... 
Sacral plexus 
Perineum, anus, genitalia. 
Inferior hemorrhoidal, 
perineal, cuta n e o u s, 
dorsal of penis. 
Radial 
Sensation 
Musculocutaneous ... 
Thumb and three fingers.. 
External and internal. 
Sacral (five) 
Motion and sensation... 
Cord 
Multifidus spinse, skin, 
gluteal region. 
Filaments and sacral 
plexus. 
Saphenous (external 
or short). 
Sensation 
Internal popliteal.... 
Integument of foot and 
little toe. 
Filaments. NERVES 
NERVES 
NERVES, TABLE OF PRINCIPAL. 
Name. 
Function. 
Origin. 
Distribution. 
Branches 
Saphenous (long or 
internal). 
Sensation 
Anterior crural 
Knee, ankle 
Cutaneous, patellar,com- 
municating, filaments. 
Sciatic (great) 
Motion and sensation... 
Sacral plexus 
Skin of leg, muscles of 
back of thigh and those 
of leg and foot. 
Articular, muscular, pop- 
li teals. 
Sciatic (small) 
Sensation and motion... 
Sacral plexus 
Perineum, back of thigh 
and leg, gluteus maxi- 
mus. 
Muscular, cutaneous, 
long pudendal. 
Spinal accessory 
(eleventh cranial). 
Motion 
Floor of fourth ven- 
tricle. 
Sternoc leidomastoid, 
trapezius. 
Filaments. 
Splanchnic (great)... 
Sympathetic 
Thoracic ganglia 
Semilunar ganglion, renal 
and suprarenal plexuses. 
Communicating and 
filaments. 
Splanchnic (lesser).. . 
Sympathetic 
Tenth and eleventh 
thoracic ganglia, 
great splanchnic. 
Celiac plexus and great 
splanchnic. 
Communicating and 
filaments. 
Splanchnic (renal or 
smallest). 
Sympathetic 
Last thoracic ganglion 
Renal and celiac plexus... 
Communicating and 
filaments. 
Stylohyoid 
Motion 
Facial 
Stylohyoid muscle 
Filaments. 
Subscapular (three).. 
Motion 
Brachial plexus 
Subscapular, teres major, 
and latissimus dorsi. 
Filaments. 
Supraacromial 
Sensation 
Cervical plexus 
Skin over deltoid 
Filaments. 
Supraclavicular (de- 
scending). 
Sensation 
Third and fourth cer- 
vical. 
Skin of neck, breast and 
shoulder. 
Sternal, clavicular, acro- 
mial. 
Supramandibular.... 
See Maxillary, superior. 
Supramaxillary 
See Maxillary, superior. 
Supraorbital.. 
Sensation 
Ophthalmic 
Upper lid, forehead 
Muscular, cutaneous and 
pericranial branches. 
Suprascapular 
Motion and sensation... 
Brachial plexus 
Scapular muscles. 
Filaments. 
Supratrochlear 
Sensation 
Ophthalmic 
Forehead and upper eye- 
lid. 
Muscular and cutaneous. 
Temporal 
Motion 
Inferior maxillary.... 
Temporal muscle 
Filaments. 
Temporal 
Sensation 
Orbital 
Integument over temporal 
muscle. 
Filaments. 
Temporal 
Motion 
Temporofacial 
Orbicularis palpebrarum, 
occipitofrontalis, attra- 
hens and attollens aurem, 
corrugator supercilii. 
Muscular. 
Temporal, superficial 
Sensation 
Auriculotemporal .... 
Integument over temporal 
fascia. 
Filaments. 
Temporofacial 
Motion 
Facial 
Upper part of face 
Temporal, malar, infra- 
orbital. 
Thoracic (ant. and 
ext.). 
Motion 
Brachial plexus 
Pectoralis major et minor. 
Filaments. 
Thoracic (posterior 
or long). External 
respiratory nerve of 
Bell. 
Motion 
Brachial plexus 
Serratus magnus 
Filaments. 
Tibial (anterior) 
Motion and sensation... 
External popliteal ... 
Tibialis antic., extensor 
long, digit., peroneus ter., 
joints of foot, skin of 
great toe. 
Muscular, external, in- 
ternal. NERVES 
NERVES, INJURIES 
NERVES, TABLE OF PRINCIPAL. 
Name. 
Function. 
Origin. 
Distribution. 
Branches. 
Tibial (posterior).... 
Motion and sensation . .. 
Internal popliteal.... 
Tibialis post., flexor long, 
digit., flexor long, pollic., 
skin of heel and sole, 
knee-joint. 
Plantars, muscular, cal- 
caneoplantar, cuante- 
ous or internal calca- 
nean, articular. 
Tonsillar 
Sensation 
Glossopharyngeal 
Tonsil, soft palate, and 
fauces. 
Filaments. 
Trigeminus or trifa- 
cial (fifth cranial). 
Motion and sensation 
(taste). 
Medulla and floor of 
fourth ventricle. 
Skin and structures of 
face, tongue and teeth. 
Ophthalmic,superior and 
inferior max. divisions. 
Trochlear 
See Patheticus. 
Ulnar 
Motion and sensation. .. 
Brachial plexus 
Muscles, shoulder-j o i n t 
and wrist-joint, and skin 
of little finger. 
Two articular, muscular, 
palmar cutaneous, dor- 
sal, superior palmar, 
deep palmar. 
Vagus 
See Pneumogastric. 
Vidian 
Sensation 
Union of large super- 
ficial and deep pe- 
trosal. 
Sphenomaxillary fossa, 
and posterior part of 
upper nasal meatus. 
Filaments, nasal. 
NERVES, DISEASES.-S ee Neuralgia, 
Neuritis, Neuroma, etc. 
NERVES, INJURIES. Wounds.-A nerve may 
be completely or partially divided, and the 
wound may be incised, lacerated, contused, or 
punctured. 
The effects of wounds of nerves, in addition to the 
degeneration of the portion below the wound, are: 
(1) Paralysis of motion and sensation of the parts 
supplied by the nerve; (2) subsequent wasting, 
atrophy, and fatty degeneration of the paralyzed 
muscles; (3) certain trophic changes in the tissues 
whose nutrition is presided over by the injured 
nerve, such as a glazed, smooth, cold, and bluish- 
red condition of the skin, falling off of the hair, 
cracking and deformity of the nails, local ulcera- 
tions and gangrene of the fingers, etc.; (4) a marked 
diminution in the temperature of the part, which 
may be preceded for a few days or even a few weeks 
by a slight increase of 2 or 3 degrees; (5) affections 
of the joints resembling rheumatism, and apt to 
terminate in more or less complete ankylosis; 
(6) ascending neuritis, which is attended by severe 
pain in the cicatrix and shooting up the nerve, and 
pain in the area of its distribution; and (7), very 
rarely, changes in the nerve-centers of a functional 
or of an organic nature (Walsham). 
Symptoms.-The immediate symptoms are loss 
of function in the parts supplied by the nerve- 
viz., muscular paralysis, local anesthesia, or loss 
of special sense-according as a motor, sensory, 
or nerve of special sense is injured. In the case of 
a mixed nerve, both motion and sensation will 
be lost; but sensation in some instances may be 
partially restored in a few days through anasto- 
mosing branches from other nerves. The remoter 
symptoms are wasting of the muscles, and the 
trophic changes of the skin, nails, etc., already 
alluded to, and sometimes pain in the cicatrix, 
and in the course of the nerve and its peripheral 
distribution. The muscles exhibit to electric 
tests the reaction of degeneration-i. e., they do 
not respond to the faradic current, but contract on 
the application of a continuous current of less 
strength than that necessary to cause the contrac- 
tion of normal muscles; the contraction elicited, 
moreover, is slow, long, and tetanic; and the se- 
quence of polar reaction is altered (ACC.> CCC. 
instead of CCC.> ACC.). Their response, however, 
to the continuous current becomes feebler until they 
finally cease to contract. As a consequence of the 
degeneration of the affected muscles, their op- 
ponents undergo adaptive shortening, thus pro- 
ducing various deformities: as, for example, the 
hammer fingers (main en griffe) seen after division 
of the ulnar nerve. 
The treatment varies according as the wound of 
the nerve is recent or of long standing. In the 
former case the nerve should be sought in the 
wound, the divided end sutured, the limb placed 
at rest on a splint in such a position that the 
united ends are not subjected to tension, and every 
effort subsequently made to obtain healing of the 
wound of the soft parts by first intention. If the 
divided ends of the nerve are lacerated or contused, 
the injured portions should be cleanly cut away 
before applying the sutures. If the nerve is only 
partially divided, the divided parts should be 
sutured. The sutures, consisting of fine China- 
silk twist, should be passed with a small curved 
needle through the sheath of the nerve in 4 or 5 
places. In every recent wound it should be as 
much a matter of routine to suture large nerves, 
i f divided, as to tie wounded arteries. If the nerve 
does not unite, an attempt may be made to pro- 
cure union after the wound is healed, as may 
also be done in long-standing cases of nonunion, 
though many months or even a year or two may NERVES, INJURIES 
NERVOUS DISEASES, EXAMINATION 
have elapsed. An incision over the ununited 
ends should be made parallel to the nerve, the bul- 
bous upper end of which can generally be felt 
through the soft tissues. The ends, which may have 
retracted so as to be an inch or more apart, should 
be sought, the bulbous ends shaved away little 
by little with a sharp scalpel until plenty of nerve- 
fibers are seen on the surface of the section, the 
lower end also refreshed, and the two united in 
the manner described above. When the ends 
are embedded in much cicatricial tissue, they 
should be freed by careful dissection, and when 
much separated, stretched so as to bring them 
into apposition. If the nerve is only partially 
divided, and the divided portions are bound 
down by cicatrical tissue, the injured segment of 
nerve, in its entire thickness, should be cut away 
before applying the sutures. In some instances 
sensation may return within 24 hours of suture; 
but it may be more than a year in long-standing 
cases before the function of the nerve is restored. 
In the meanwhile the nutrition of the parts sup- 
plied by it should be promoted by warmth, and 
the muscles prevented as much as possible from 
degenerating by galvanism, massage, friction, and 
passive movements (Walsham). 
Transplantation of nerves, or nerve-grafting, 
has become a recognized surgical procedure. In 
some cases, also, a piece of nerve has been taken 
from an animal for the purpose. An attempt to 
restore the function of the nerve in this way may 
be made when the proximal and the distal ends 
of a divided nerve cannot be brought into apposi- 
tion: as, for instance, after a portion of nerve has 
been destroyed in a compound fracture, or after 
a porton of nerve, damaged by the contraction of 
cicatricial tissue, by the formation of callus, or by 
the growth of a tumor in its substance, has been 
removed. The conditions for success are: great 
care in dissecting out and handling the nerve, its 
immediate transference, the employment of a 
single suture at each end, the avoidance of all 
tension, strict asepsis, and immediate union of the 
wound of the soft parts. 
Subcutaneous rupture of a nerve is rare, but is 
occasionally met with as the result of a severe 
twist or wrench. It is attended with severe pain 
at the time of injury, perhaps also referred to the 
periphery of the nerve, and the gradual formation 
of a bulbous swelling on the nerve immediately 
above the rupture. The same effects follow as in 
division of a nerve in an open wound. The treat- 
ment is also similar. 
Compression of a nerve occasions numbness and 
tingling, and, if severe and prolonged, partial or 
complete paralysis of the parts supplied by it, and 
the series of changes already described. As ex- 
amples may be mentioned crutch-palsy, due to the 
pressure of a crutch upon the large nerves in the 
axilla; the dropped wrist, from the involvement 
of the musculospiral nerve in the callus in fracture 
of the humerus; the tingling, numbness, and par- 
tial paralysis sometimes following dislocations of 
the shoulder from the pressure of the head of the 
displaced bone on the brachial plexus; the pain 
caused by the pressure of a tumor on a nerve; the 
"pins and needles" felt in the feet, after sitting on 
the edge of a chair, from compression of the sci- 
atic nerve, etc. 
The treatment consists in releasing, if practica- 
ble, the nerve from the compressing agent. If a 
wound of the soft tissues is necessary to accom- 
plish this object, healing without suppuration 
should be obtained, if possible, as otherwise the 
nerve may again become compressed by the 
resulting scar-tissue. 
Contusions.-A familiar example of this injury 
is a blow on the ulnar nerve, as it lies behind 
the internal condyle. There is intense pain 
at the spot struck, and shooting and "pins- 
and-needles" pains in the parts supplied by the 
nerve. These symptoms pass off shortly, but 
occasionally they may be more severe and last 
for several weeks, in which case there is prob- 
ably some effusion of blood in the nerve. In rare 
instances ascending neuritis, persistent neuralgia, 
or even paralysis, and changes similar to those 
observed after complete division of a nerve, may 
follow. 
Foreign Bodies.-A portion of a needle broken 
off in a nerve, the lodgment of small shot from a 
gun accident, etc., may give rise to inflammation 
of the nerve, persistent irritation and pain at 
the injured spot, spasm in the muscles, and 
pain or tingling in the parts supplied by the 
nerve. Such accidents have occasionally been 
followed by epileptiform convulsions. The treat- 
ment is to cut down upon and remove the foreign 
body. 
NERVOUS DISEASES, EXAMINATION. 
Mode of Procedure in Diagnosing Diseases of the 
Nervous System. 
In making a diagnosis of diseases of the nervous 
system it is frequently advisable to resort to the 
plan of exclusion, and in this manner to eliminate 
such disorders as rheumatism, gout, and diseases 
of the joints, affections which disturb sensation or 
motion, or both. As syphilis is a very common 
cause, in diseases of the nervous system the possi- 
bility of such infection, even many years before 
the onset of the nervous symptoms, should be 
determined. For a full discussion of the diagnosis 
of syphilis, see Syphilis. 
In all lesions of the nervous system there is 
either a disturbance of motion or of sensation, 
or of both. In some there is a disturbance of 
the special senses or of consciousness. It is 
necessary then to separate diseases of the brain, 
diseases of the cord, and diseases of the peripheral 
nervous system. The elimination of eyestrain 
is of paramount importance in all nervous dis- 
orders. 
A careful history will eliminate such condi- 
tions as gout, rheumatism, and joint affections. 
After these factors have been eliminated, it is 
determined whether or not the lesion is within 
the brain, in the spinal cord, or in the peripheral 
nerves. Spinal curvature may be found to be the 
cause. NERVOUS DISEASES, EXAMINATION 
NERVOUS DISEASES, EXAMINATION 
Symptoms of Diseases of Brain, Spinal Cord, and 
Peripheral Nerves. 
condition allied to hysteria in which the attempt 
to stand results in a sudden violent contraction 
of the leg muscles. 
Lesions of 
Brain. 
Lesions of 
Cord. 
Lesions of Peri- 
pheral Nerves 
1. Disturbances of 
consciousness. 
2. Disturbances of 
special sense, as 
hearing, smelling, 
tasting, feeling. 
3. Delusions and 
hallucinations. 
4. Paralysis fre- 
quently involves 
arms. 
5. Convulsi ons 
common. 
6. Vomiting com- 
mon. 
7. Sphincters fre- 
quently involved. 
1. Consciousness 
usually preserved. 
2. No disturbance 
of nerves of 
special sense. 
3. No delusions 
or hallucinations. 
4. Paralysis fre- 
quently involves 
legs. 
5. Convulsions 
rare. 
6. Vomiting not 
common, except 
in tabes dorsalis. 
7. Sphincters fre- 
quently involved. 
1. Cons ciousness 
preserved. 
2. No disturbance of 
nerves of special 
sense except feel- 
ing. 
3. Mind usually nor- 
mal. 
4. Paralysis may in- 
volve arm or leg, 
most frequently the 
latter. 
5. Convulsions 
rare. 
6. Vomiting uncom- 
mon. 
7. Usually control of 
sphincters. 
Tremors. 
Tremors are involuntary vibratory movements 
and are produced by alternate contraction and 
relaxation of antagonistic muscles. They are ob- 
served most often in the arms, head, face, tongue, 
and hands. They may be coarse or fine. Tremors 
occur in chronic alcoholism, delirium tremens, 
paralysis agitans, and in poisoning by lead, 
mercury, arsenic, chloral and opium. Neuras- 
thenia, debility from various causes, senility, 
hysteria, disseminated sclerosis, and paresis are 
accompanied by tremors. In disseminated sclero- 
sis, the tremor is irregular, jerky, and increased 
by voluntary efforts to restrain it. The tremor 
is absent during rest but is brought about by 
movement. In paralysis agitans, it is regular 
and rhythmic, occurring both during rest and 
movement. The tremor of senility is exceedingly 
fine and begins in the hands, often extending to 
the face. It occurs at first only during motion, dis- 
appearing during rest. When age is far advanced 
it may occur during both rest and movement. 
Choreiform movements are coarse, incoordi- 
nated, involuntary movements of a jerky and 
irregular character usually separated by short 
intervals. They may simulate, to some extent, 
purposeful movements. Among the causes may 
be mentioned idiopathic chorea, Huntingdon's 
chorea, posthemiplegic chorea, organic brain 
disease, habit, hysteria, reflex irritation, etc. 
Athetoid movements are slow, more or less 
rhythmic twisting movements of the fingers and 
toes. They are observed in cerebral palsies of 
children, after hemiplegia in adults, and polioen- 
cephalitis. 
Systematic Study of Diseases of the Nervous 
System. 
(1) Disturbances of motion; (2) disturbances of 
sensation; (3) disturbances of nutrition; (4) dis- 
turbances of consciousness; (5) disturbances of 
special sense; (6) psychic disturbances. 
Paralysis. 
Varieties.-1. Irregular paralysis, arising from 
various regions of brain, giving rise to optic 
neuritis, vomiting, strabismus; or, if in the cord or 
peripheral nervous system, giving rise to paraple- 
gia, neuritis, etc. 
2. Monoplegia, arising from brain, as seen in 
small hemorrhage into cortical layer; or may arise 
from disease of peripheral nerve, as from 
traumatism. 
3. Hemiplegia.-Hemorrhage into the cerebrum 
is the most common cause. Hemorrhages into 
cerebellum and crus cerebri are very rare. 
Paraplegia may arise from hemorrhage into 
brain or cord, or it may arise from disease of per- 
ipheral nerves, as in multiple neuritis. 
The Gait. 
The Ataxic Gait.-In locomotor ataxia the 
characteristic development of incoordination of 
movements comes on slowly. It is frequently 
observed by the patient from the inability to 
walk after dark. The characteristic gait is mani- 
fested by the fact that the foot is raised high in the 
air with a rotatory motion, and is dropped quickly 
so that the whole of the sole strikes the floor at the 
same time. 
The Spastic Gait.-In spastic paraplegia or lateral 
sclerosis, the gait is manifested by the legs being 
dragged behind the patient, the toes frequently 
scraping the ground; the knees seem to come 
together and the limbs may shake from the clonus 
which may be present. 
Festination is observed in paralysis agitans. In 
this movement the patient appears to be in the act 
of falling forward, when the steps become faster 
and faster, then suddenly cease, and the patient 
may fall backward or on the side, should he receive 
no support from in front. 
The Gait of Pseudomuscular Hypertrophy.-The 
limbs are generally well nourished, frequently 
greatly enlarged, and in walking the feet are 
thrown outward straddling; the abdomen is greatly 
Varieties.-(1) Epileptiform; (2) tetanic; (3) 
hysteroid; (4) local. 
In epileptiform convulsion consciousness is lost, 
and there are clonic spasms. 
Tetanic convulsions are usually accompanied by 
consciousness, and the muscles most frequently 
affected are the muscles of the jaws and of deglu- 
tition. They occur in tetanus, strychnin-poison- 
ing, tetany and spinal meningitis. 
Hysteroid convulsions occur in hysteria; con- 
sciousness may or may not be present. 
Local convulsions or spasms frequently affect 
the face, causing momentary spasms, as is seen 
in tic douloureux, which results from neuralgia 
of the fifth nerve. 
Saltatory Spasm.-A transient or permanent 
Convulsions. NERVOUS DISEASES, EXAMINATION 
NERVOUS DISEASES, EXAMINATION 
enlarged, and the body movements are slow and 
awkward. 
Titubation is observed in diseases of cerebellum. 
It may be mistaken for the gait of locomotor 
ataxia, except that it is more irregular. If the 
patient is put in the reclining attitude, the motions 
may be perfectly controlled, while in locomotor 
ataxia there is partial loss of voluntary motion, as 
is seen when the patient tries to touch the tip of 
the nose when the eyes are closed. 
In myotonia (q. v.j any muscular action such as 
walking is begun with difficulty. The stiffness 
gradually, however, disappears and progression is 
easy. 
In intermittent claudication (q. v.j walking is 
associated with rigidity, numbness, cramps, 
weakness and disorders of sensation. 
duced by faradism may similarly persist. More 
rarely it may be induced in the flexors of the leg 
and forearms. It has been observed in early 
tabes dorsalis, multiple sclerosis, hysteria, and 
paralysis agitans. 
Vasomotor Disturbances. 
Paralysis of the vasomotor system occurs as a 
symptom of hysteria, neurasthenia, and other 
functional neuroses, and follows injuries of the 
sympathetic nerve. It is manifested by abnormal 
redness of the skin with a sensation of heat and a 
rise in the dermal temperature. Vasomotor 
spasm is indicated by pallor and coolness of the 
skin with formication and stiffness. It is observed 
with functional disturbances of the sympathetic 
system and may be followed by trophic disturb- 
ances such as occur in scleroderma and symmetric 
gangrene. 
The Reflexes. 
As a rule, when the "reflexes" are spoken of in 
diseases of the nervous system, the tendon or 
patellar reflex of the knee-joint is meant: this is 
probably due to the contraction of the muscle it- 
self, brought about by its normal irritability. As 
the impulse communicated to the muscle is trans- 
mitted through the medium of the spinal cord, it 
may be said that the reflexes are governed by this 
portion of the nervous system. 
The Knee-jerk or Patellar Reflex.-This symp- 
tom is elicited by having patient cross the knees 
while in a sitting posture, and after distracting 
attention, gentle taps are made over quadriceps 
tendon immediately below the patella. 
The knee-jerk is increased in lateral sclerosis, 
disseminated sclerosis, incomplete lesions of the 
cord above the lumbar segment, irritability of the 
spinal cord such as occurs in spinal meningitis, 
strychnin poisoning, hysteria, etc., and in some 
cases of organic cerebral disease. 
The knee-jerk is decreased in locomotor ataxia, 
neuritis, pseudomuscular hypertrophy, poliomye- 
litis, myelitis, and in poisoning by spinal depressant 
drugs. Pronounced physical exhaustion also 
serves to lessen the tendon reflexes. 
Ankle-clonus.-This symptom is elicted by 
allowing patient to cross the knees, and by elevat- 
ing the foot so that the entire limb is on the same 
plane, then, by a sudden push upward, there is a 
tremulous movement or vibration communicated 
to the hand, frequently lasting for many seconds. 
The Babinski reflex is the extension of the great 
toe which follows tickling the sole of the foot. 
Normally flexion follows such a procedure. The 
reflex occurs most often in hemiplegia, diplegia, 
and diseases of the motor tract of the cord. 
Arm-jerk and jaw-jerk are also frequently 
elicited. 
Paradoxic contraction, a peculiar phenomenon 
allied to the reflexes, first studied by Westphal, is 
occasionally noted. Its cause is unknown. In 
the tibialis anticus muscle it is induced by forcibly 
flexing the foot on the leg. As a result, the foot 
remains thus flexed for a considerable time, then 
slowly relaxes. On repeating the flexion,' the 
tetanic contraction recurs, but the response gradu- 
ally diminishes in intensity. Contractions in- 
Disturbances of Sensation. 
Loss of sensation is most common. This is 
called anesthesia. Hyperesthesia is a condition in 
which the sensation is increased above the normal. 
Paresthesia consists of abnormal sensations, such 
as "pins-and-needles" pains. Subjective painful 
sensations or nerve ache is known as neuralgia. 
Areas of anesthesia may be determined by the 
prick of a pin, by the finger stroke, by the applica- 
tion of heat (flame or coal) or cold (ice), and by the 
faradic current. Monanesthesia is a condition in 
which the sensation is lost in but one member. 
Hemianesthesia means loss of sensation over the 
lateral half of the body. Analgesia means in- 
sensibility to pain. It is met with in hysteria and 
syringomyelia especially. 
Disturbances of Consciousness. 
The principal alterations to which consciousness 
is subject in nervous diseases are coma, trance, 
somnambulism, ecstasy, and catalepsy. 
Coma is an abnormally deep and prolonged 
sleep in which the cerebral functions are in abey- 
ance, characterized by stertorous breathing, re- 
laxation of the sphincters, lividity of the face, loss 
of parallelism of the optic axes, and an inability to 
respond to external stimuli. It may be gradual or 
sudden in its onset; complete or partial, transient 
or permanent. It may be due to organic brain 
disease, traumatism, cerebral anemia, epilepsy, 
sunstroke, hysteria, various convulsive states, 
and various toxic agents in the blood, introduced 
either from without or produced within the body. 
Trance is an hysteric manifestation characterized 
by a prolonged abnormal sleep from which the 
patient cannot be aroused and in which the vital 
functions are reduced to a minimum. 
Somnambulism is a condition of half-sleep in 
which the senses are but partially suspended and 
the patient is able to perform various feats auto- 
matically. Ordinary sleep-walking may occur in 
health but the more pronounced varieties of this 
condition are observed in hysteria and in hypno- 
tized subjects. 
Ecstasy is a peculiar state of the mind in which a 
delusion so governs the mental functions that the NERVOUS DISEASES, EXAMINATION 
galvanic battery there are what are termed the 
anode, or positive pole, and the kathode, or negative 
pole. By placing the kathode over a normal 
muscle and closing the circuit, a strong contraction 
occurs; when the anode is placed over the normal 
muscle, the contraction is greatly lessened. There 
is no contraction in either case when the circuit is 
broken. With a strong galvanic current contrac- 
tions of the normal muscle occur, and the anodal is 
greater than the kathodal. In the reaction of 
degeneration all these reactions are altered or even 
reversed. 
Another simple degenerative reaction is given by 
Gowers, who states that the faradic irritability is 
lost, while the galvanic irritability is increased, 
and often changed in quality. 
The circuit of a galvanic battery is said to be 
closed, made, or complete when the elements are 
connected outside of the fluid. 
NEURALGIA.-A severe paroxysmal pain in 
the area of distribution of a nerve or along its 
course. 
Etiology.-Age, sex, heredity, and anemia are 
important predisposing causes. The true nature 
of neuralgia is obscure; it is possible that in many 
cases the cause is an inflammatory or circulatory 
disturbance in the nerve-trunk. Among exciting 
causes, cold and traumatism play an important 
role. Certain disease-poisons, as those of typhoid 
fever, variola, malaria, and metallic poisons, such 
as lead, arsenic, copper, mercury, in addition to 
alcohol and nicotin, are sometimes causative 
agents of neuralgia. Gout and diabetes also 
occasionally give rise to neuralgia. Finally, 
there is a class of so-called reflex neuralgias, such 
as those due to eye-strain and those met with in 
connection with uterine and ovarian disease and 
occurring in remote organs. Lesions of the 
central nervous system also give rise to attacks 
of neuralgic pain. 
Varieties.-According to the nerves involved, 
the following varieties occur: Trifacial, or tic 
douloureux (prosopalgia); cervicooccipital, cervico- 
brachial, and brachial neuralgias; neuralgia of 
the phrenic nerve; neuralgias of the trunk, such 
as dorsointercostal, lumboabdominal, and possi- 
bly pleurodynia; neuralgia of the spinal column, 
sacral neuralgia, and coccygodynia; neuralgia of 
the feet; and visceral neuralgia. The fifth nerve 
is a favorite seat for reflex neuralgias. 
Symptoms.-Pain is the most important symp- 
tom. It is of a spontaneous nature; occurs in 
paroxysms; runs along the course of the nerve by 
the nervi nervorum; and is of a darting, burning 
character. These paroxysms, lasting from a few 
moments to some hours, may return at regular 
intervals. Certain tender points exist along the 
course of the nerve, usually where the nerve 
passes from a deeper to a more superficial position. 
These pains are supposed to be caused by sudden 
explosions in the ganglionic cells in the gray 
matter of the cerebrum, where all nerve-fibers 
terminate. Other symptoms of neuralgia are 
numbness, transient hyperesthesia, vomiting and 
various vasomotor disturbances. 
Diagnosis is usually easy. Neuralgia may be 
NEURALGIA 
entire nervous system is held in a condition of 
subjection or apparent insensibility. It is usually 
an hysteric manifestation. 
Catalepsy is characterized by loss of will and by 
muscular rigidity. It occurs in paroxysms with 
loss of consciousness, the limbs remaining for long 
periods in any position in which they are placed. 
It occurs in hysteria, various psychoses, hypnotic 
states, and organic brain disease. 
Disturbances of the Special Senses. 
Miosis, or contraction of the pupil, frequently 
occurs in opium-poisoning, locomotor ataxia 
paretic dementia, and uremia. 
Inequality of the pupils may be found in such 
conditions as organic brain-disease, locomotor 
ataxia, and paretic dementia. 
The Argyll Robertson pupil occurs in locomotor 
ataxia. In this phenomenon the pupil fails to 
respond to light, but accommodates for distance. 
See Pupil. 
Nystagmus.-A peculiar condition of the eye- 
ball in which an outward and an inward oscillation 
occurs. It may be observed in disseminated 
sclerosis and diseases at the base of the brain. 
Ocular movements are often impaired or para- 
lyzed, and the muscles involved give evidence of 
the nervous lesion. See Eye-muscles. 
The Ear. 
Tinnitus aurium is a peculiar ringing or buzzing 
sound in the ear observed in middle-ear or M^nidre's 
disease. It may be produced by administering 
large doses of quinin or salicylic acid. See Ear. 
Psychic Disturbances. 
Delusion.-By this is meant a faulty belief con- 
cerning a subject of physical demonstration, out 
of which the person cannot be reasoned by ade- 
quate methods for the time being (Wood). 
Illusion means a perverted conception, attribut- 
ing life and motion to inanimate things. 
Hallucination.-A false perception. Frequently 
occurs in the insane, and is one in which the pa- 
tient appears to hear voices and to see faces where 
none exist. 
Morbid Impulse.-An irresistible desire to com- 
mit an act which the patient knows to be wrong 
(Stevens). 
Disturbances of Nutrition. (Trophic 
Derangements.) 
By this term is meant changes in the nerves and 
muscles of a part, giving rise to a change in the 
contractility when a galvanic battery is applied 
and resulting also in muscular atrophy, arthro- 
pathies, ulcerations, and trophic affections of the 
skin, nails and hair. These trophic or nutritive 
phenomena are closely related to vasomotor 
phenomena. 
Reaction of Degeneration. 
To determine this reaction, a galvanic battery 
of moderate strength should be used. The battery 
should always be tested by dipping the sponges 
in a weak saline solution or in water. In the NEURALGIA 
NEURASTHENIA 
distinguished from organic disease of a part by 
the presence of great superficial tenderness, by a 
hysteric temperament, and by the absence of all the 
other symptoms of organic disease; from neuritis, 
by the intermittent nature of the pain, by its oc- 
curring in hysteric subjects, and by the absence 
of the constitutional symptoms of inflammation. 
When neuritis and neuralgia exist together, the 
diagnosis may be difficult. Here the presence of 
superficial tenderness and a relief of the pain by 
deep pressure points to neuralgia, while in neu- 
ritis, on deep pressure the pain is extreme. The 
severe forms of neuritis are followed by anesthesia 
and muscular wasting, with changes in muscular 
irritability. In compression of nerves the pain is 
continuous, and the symptoms and consequences 
of neuritis will sooner or later ensue. Muscular 
rheumatism differs in its localization in muscles 
and groups of muscles. It is continuous, and the 
pain increases on motion. 
The treatment of pain during the paroxysm 
calls for the administration of powerful anodynes. 
Morphin and opium and their preparations are 
foremost, and should be given in full doses by the 
mouth or hypodermically. Acupuncture and 
hypodermic medication may be combined. In 
sciatica this is probably the best treatment. 
Cocain hypodermically (1/4 of a grain) may be 
preferred to morphin. 
Ammonium chlorid, 20 grains in solution, may 
be given every 4 hours. Quinin is to be used when 
a malarial origin is suspected. Antipyrin, ace- 
tanilid, acetphenetidin, and salol sometimes act 
with rapidity. Exalgin gives relief, but without 
diminishing the tendency to future paroxysms. 
The following may be administered: 
1$. Acetanilid, gr. xx 
Citrated caffein, gr. x 
Camphor monobromate, gr. v. 
Make 10 pills; give 1 pill every 2 hours. 
Cannabis indica, in doses of 1/2 grain of the 
extract, is efficacious in neuralgias of the pelvic 
region and in neuralgia in migraine sufferers. 
Gelsemium and its alkaloids are valuable for the 
affection confined to the dental branches of the 
fifth nerve. Chloral has been recommended, but 
almost always fails. Croton-chloral or butyl- 
chloral has been recommended for neuralgia of 
the fifth nerve. It may be administered to ad- 
vantage in combination with cannabis indica, as 
follows: 
1$. Butyl-chloral hydrate, gr. c 
Extract of cannabis indica, gr. ijss. 
Divide into 20 pills. Give 1 pill every 3 
hours. 
Chloroform and ether may be used as inhala- 
tions, to give speedy relief in desperate attacks 
of neuralgia, while amyl nitrite, nitroglycerin, 
and other nitrites give the best chance of relief 
in cardiac neuralgic conditions. Recently, castor 
oil has been highly recommended. It is given 
before breakfast in doses of from 1 to 2 ounces. 
Belladonna and atropin are drugs long em- 
ployed in the treatment of neuralgia. They are 
probably of more benefit in the abdominal and 
pelvic varieties than in facial neuralgia. Bella- 
donna is used locally, moreover, often with relief. 
Hyoscyamus, hyoscin, and stramonium are em- 
ployed in much the same way as belladonna. 
The following may be tried: 
I). Tincture of hyoscyamus, 
Tincture of stramonium, 
Tincture of belladonna, 
each, 5 iv. 
Give 25 drops in a tablespoonful of water 
every 4 hours. 
Of local applications, pressure may relieve mild 
cases. Menthol, ointments of veratrin and 
aconite, the tincture of aconite painted over an 
involved area, the extract of belladonna, thinned 
with glycerin, and the oleate of morphin are of 
service. Blisters, (by chloroform, either pure or 
diluted) sinapisms and camphor may be used. 
Cocain will act on mucous surfaces, but not on 
the skin. Acupuncture and aquapuncture are 
employed. Chloroform, osmic acid, and phenol 
have been injected hypodermically. 
Freezing the part with ether spray often 
proves useful. The continuous electric current 
may be used, placing the positive sponge near the 
seat of pain, and with the negative gently rubbing 
the neuralgic spot until the skin is slightly red- 
dened, and until it causes a faint tingling or 
burning, but not pain. 
In the most intractable cases the surgical 
means that may be tried are nerve stretching or 
excision of a portion of the nerve. Of the two 
operations the latter is to be preferred, but too 
often the pain returns after it. In fact, the opera- 
tion can only be of use when the pain is pe- 
ripheral, due to some irritation existing between 
the part cut and the ends of the nerve. If the 
neuralgia depends upon any central cause, or if 
the irritation exists higher up than the point 
divided, the operation has always eventually 
failed, although at times a temporary cessation of 
pain for a few weeks has occurred. See Lumbago, 
Sciatica, etc. 
NEURASTHENIA.-Neurasthenia is a nervous 
state or condition marked by irritable weakness. 
It is commonly known as nervous prostration or 
nervous exhaustion, and presents a great many 
variable and inconstant subjective symptoms and 
a few significant objective phenomena. All forms 
of nervous energy-mental, motor, and organic- 
are disturbed, so that fatigue in these various 
spheres is more quickly occasioned than in health. 
Etiology.-The majority of cases occur during 
the age of reproductive activity, and the disorder 
is rare after the age of 50. It sometimes occurs in 
childhood and during adolescence in individuals 
of a pronounced neuropathic tendency. Both 
sexes are about equally subject to it. High alti- 
tude and extremes of climatic conditions favor 
its development. Hebrews, Slavs, and Scandi- 
navians are especially subject to it. A neuro- 
pathic heredity commonly furnishes the field in NEURASTHENIA 
which it develops. Debilitating conditions in the 
antecedents are very common; gout, rheumatism, 
tuberculosis, syphilis, excesses, malaria, and all 
the various cachexias in parents are likely to be 
followed by neurasthenia in the offspring. 
Among the inciting causes, overwork or over- 
strain of any kind is the most potent. Anxiety, 
worry, disappointment, excesses, deprivation of 
sleep, and anything that makes continuous and 
exacting demands upon the endurance of patients 
may induce this condition of nervous exhaustion. 
Traumatism, especially when attended by fright 
and shock, and mental shocks of all varieties may 
induce it with great readiness and sometimes 
suddenly. It may be symptomatic of or second- 
ary to all sorts of chronic diseases and various 
toxic states, such as lithemia, alcoholism, and 
syphilis. Most cases present a multiplicity of 
predisposing exciting causes. 
Dana sums up the - leading causes of neuras- 
thenia as follows: 
1. Hereditary nerve instability. 
2. Overwork and worry. 
3. Severe shocks, with or without injury. 
4. Infections. 
5. Abuse of stimulants and narcotics. 
6. Abuse of sexual functions. 
7. Disorder of digestive functions and auto- 
toxemia. 
This means that the causes are most often a bad 
heredity and foolish living. 
Pathology.-The pathologic anatomy of neuras- 
thenia is not known. The best conception of the 
development of this disorder is obtained from a 
consideration of the changes which take place in 
motor cells when subjected to natural fatigue, as 
demonstrated by Hodge. It seems probable that 
when cells are continually overtaxed, recupera- 
tion and a full restoration of their potential energy 
do not take place except after a prolonged rest, 
and it is conceivable that in certain instances res- 
toration may be impossible. 
Symptoms.-The most important and com- 
monly encountered symptoms in neurasthenia are 
headache, backache, gastrointestinal atony, neuro- 
muscular weakness, cerebral depression, mental 
irritability, and insomnia. To these may be 
added an almost infinite number of subjective 
complaints, which vary in different cases, and even 
in the same case. They' may all be considered 
systematically, as follows: 
Motor Disorders.-Muscular weakness is con- 
stantly found. This is commonly demonstrated 
by the ready fatigue upon exertion. Often the 
patient is able to put forth an ordinary amount 
of strength for one or two efforts, and thereafter 
is left weak and trembling. Constant effort is 
impossible. Tremor is frequently present, and is 
easily provoked by muscular effort. It may be 
present in any of the extremities, and is often 
seen in the face and lips, especially when the 
patient is embarrassed or mentally disturbed. 
The tendon reflexes are generally intensified. 
This is particularly true of the knee-jerk. It 
sometimes happens that if the knee-jerk is re- 
peatedly elicited, the exaggeration becomes less 
and less, showing the ready fatigue of the reflex 
arc. Irritability in muscles and nerve-trunks is 
sometimes demonstrable by sharply tapping the 
parts. 
Sensory Disturbances.-Neurasthenics complain 
of many subjective sensory disturbances. A tired 
feeling is almost invariably present, and headache 
is one of the most common symptoms. It may 
be slight and constant, but more often is produced 
by muscular, and especially by mental, effort or 
by any disturbing emotion. Commonly occipital, 
it may be frontal, temporal, or vertical, and often 
is attended by a feeling of drawing in the back of 
the neck. The sensation as of a weight upon the 
head, a binding band around the brows, the lead- 
cap headache, are extremely common. Back- 
ache is usually present in neurasthenics, and is 
probably a fatigue symptom, though sometimes 
referable to a disturbance in the stomach and 
hypersensitiveness along the spine. Its common 
location is the small of the back, between the 
shoulders, and at the nape of the neck. It fre- 
quently results in the patients padding their chairs 
or retaining the recumbent position, and is usually 
intensified by any effort or disturbing circum- 
stance. Tenderness of a superficial character is 
usually found over the spine, but sometimes is 
intensified by deep pressure. The spine may be 
sensitive its whole length, but usually presents a 
number of hypersensitive points. Near the 
occiput, over the seventh cervical spine, at the 
lower end of the scapula, at the waist, at the tip 
of the sacrum, and over the coccyx are favorable 
locations for these sensitive areas. Sensitiveness 
and spontaneous pain in various portions of the 
trunk and limbs are frequently present, but the 
outlines of these sensitive and painful areas are 
not sharply defined, and are likely to shift position 
and intensity within a period of a few minutes or 
hours. Various vague sensations of heat, cold, 
prickling, tightness, numbness, stiffness, weakness, 
fatigue, soreness upon pressure, etc., referred to 
various portions of the body and limbs, or to the 
internal organs, particularly the cardiac region, 
are constantly encountered. Those having ref- 
erence to the pelvic and generative organs have in 
some cases a special prominence. 
Visual Disturbance.-Neurasthenics find reading 
more or less irksome and often impossible. Head- 
ache, ocular distress, blurring of the letters, and 
other indications of eye-strain are readily induced. 
Another difficulty is furnished by inability to 
concentrate attention. Appropriate investigation 
usually demonstrates ready fatigue of the muscu- 
lar apparatus of accommodation and a ready ret- 
inal exhaustion. In taking the chart of the 
visual fields it is a common experience to find them 
rapidly reduced within the course of a few minutes, 
and the fields for colors are usually concentrically 
contracted. Varying degrees of asthenopia mark 
a case of neurasthenia the same day, or even 
within the same hour. Heterophoric disturb- 
ances may be commonly encountered, but they 
are usually inconstant in their manifestations, and 
tend to disappear when the physical and nervous 
state of the patient is reestablished. Sometimes 
NEURASTHENIA NEURASTHENIA 
there is intense photophobia, keeping the patient 
within darkened rooms, due apparently to retinal 
hyperesthesia. Other patients complain of ob- 
scurities of vision. Hearing and smell may be 
intensified and irritable or weakened, but are 
never lost as a part of the neurasthenic symptom- 
group. Tinnitus and hyperacusia are sometimes 
encountered, and most neurasthenics are readily 
startled by sudden, slight, and insignificant noises. 
Complaints of disagreeable and peculiar odors and 
tastes are analogous disturbances. 
Gastrointestinal Disorders.-Nervous indiges- 
tion is commonly encountered. The appetite is 
often capricious, but may be excessive or dimin- 
ished. Sometimes the mere thought of food is 
repugnant. Gaseous eructations, borborygmi, 
gastric distention and dilatation, often attended by 
cardiac palpitation and precordial pain, are gener- 
ally encountered in pronounced neurasthenia. 
Hydrochloric acid may disappear from the gastric 
secretion, and digestion is usually retarded and 
inefficient, with alternating constipation and 
diarrhea. 
Circulatory Disorders.-Cardiac palpitation, due 
to gastric disturbance or provoked by slight mental 
or muscular activity, is commonly encountered, 
in some instances reaching an intense degree, at- 
tended by precordial pain, tumultuous heart 
action, throbbing and general distress, strongly 
suggestive of a stenocardial attack. The pulse 
ordinarily is rapid, and may range from 100 to 140, 
being promptly accelerated by any disturbing 
element. Anemic cases are likely to present 
exaggerated hemic murmurs, while the feebleness 
of the circulation is manifested in the cold ex- 
tremities that are usually encountered. Vaso- 
motor storms, sweating, flushing, and blushing 
are the rule, and these may be general, localized, 
or unilateral. 
Secretory Disorders.-The urine is ordinarily 
scant and of high specific gravity, with a relative 
increase of uric acid or urea and a great abun- 
dance of phosphates and oxalates. In other in- 
stances the urine may be neutral or alkaline, and 
commonly at intervals neurasthenics pass a large 
quantity of limpid urine of a low specific gravity. 
Secretions-as the perspiration, saliva, and gastric, 
intestinal, and synovial fluids-are commonly 
deficient, but may be increased, or may increase 
and decrease from time to time. 
Genital Disorders.-The average male neuras- 
thenic complains of lessened sexual power, which 
is often at first attended by nocturnal emissions, 
and if the urine shows a little cloudiness, he is at 
once convinced that he has spermatorrhea. Any 
early indiscretions are likely to be recalled, and the 
patient may become extremely morbid regarding 
his genital tract. Impotence may actually exist. 
Women have analogous conditions. 
Mental Disorders.-The mental state of neuras- 
thenia is one of its most important features. All 
the mental activities show the element of irritable 
weakness. The capacity for mental work is 
abridged, yet at times neurasthenics have mo- 
ments of great mental activity. Protracted mental 
effort, however, is irksome or impossible, the power 
NEURASTHENIA 
of attention is reduced, memory for recent events 
becomes defective, and there is general mental 
asthenia. Active spontaneous mentation and the 
flow of ideas to which the patient has been accus- 
tomed do not take place so readily, sometimes lead- 
ing them to fear that they are losing their minds, 
and they frequently state that they cannot think. 
Self-reliance and courage are frequently completely 
lost, so that the patient becomes suspicious of 
himself, apprehensive, introspective, and usually 
more or less hypochondriacal. Whatever feature 
of the disease strongly fixes his attention is dwelt 
upon, and he is likely to develop some one of the 
numerous nosophobias. The morbid self-watch- 
fulness naturally leads to depression, and neuras- 
thenics are always lacking in cheerfulness. Fears 
are their common portion. These usually are in- 
cited by some incident or have reference to some 
physical condition, and often become well- 
formulated delusions, which all but dominate the 
patient, and in certain instances become fixed 
insane delusions, then carrying the patient over 
the boundary into the field of alienism. In the 
lowered physical and mental state the patient has 
not the same interest in and affection for his 
friends and family; he becomes exacting, peevish, 
fretful, and despondent. The emotions are un- 
stable; neurasthenics, from their fears and loss of 
courage, are easily moved to tears, and sometimes 
become markedly hysteric. 
Sleep.-Disorder of sleep is one of the earliest 
features of neurasthenia, and frequently for a long 
time precedes other marked indications of the 
nervous state. As a rule, neurasthenics have 
difficulty in getting to sleep, ideas of one sort or 
another, usually unpleasant, pursue them to their 
beds, and even if they fall asleep, they are troubled 
by dreams of an unpleasant and often of an excit- 
ing, worrisome, and depressing character. Night- 
mares and formulated dreams of a disturbing sort 
are common in neurasthenia, and the patient, as 
a rule, awakes unrefreshed in the morning, being 
more despondent and hopeless than at night. 
The Physical Condition.-In neurasthenia of long 
standing general nutrition is almost invariably 
affected, and all degrees of anemia and emaciation 
may be encountered. But neurasthenia of moder- 
ate degree and character is consistent with fair 
nutrition, and often with a certain amount of 
fatness. Some of the most inveterate neurasthenics 
become quite stout, but, as a rule, neurasthenics 
are nutritionally defective. 
Forms.-Various forms of neurasthenia have 
been described, apparently depending upon the 
prominence of certain groups of symptoms. 
Spinal, cerebral, and sexual neurasthenias have 
been described, but neurasthenia is one and in- 
divisible, and all portions of the nervous apparatus 
show the disorder to some degree. In proportion, 
however, as head, spine, or pelvic symptoms 
preponderate, the particular case is modified in a 
corresponding way, and most cases of so-called 
nervous dyspepsia are merely cases of neurasthenia 
with prominence of the gastric features. Very 
many neurasthenics, especially women, develop 
hysteria, and a combination, indicated by the NEURASTHENIA 
NEURASTHENIA 
term hysteroneurasthenia, is frequently encoun- 
tered. It is very difficult to say when the dis- 
orders of neurasthenia become the defects of hys- 
teria, and as a matter of clinical fact nearly all 
hysterics present some neurasthenia. 
Course.-Neurasthenia is essentially chronic. 
Ordinarily its onset is insidious, but great moral, 
physical, or mental shocks may suddenly induce it. 
Once established, it tends to persist, and ordinarily 
the conditions which led to its development can- 
not be easily modified. Frequent remissions are 
presented, and patients once affected with neuras- 
thenia are subject to relapses, even after long 
periods of freedom. In patients under adult years 
the disease is likely to improve spontaneously and 
to recur with readiness. 
Diagnosis.-The diagnosis of neurasthenia is 
easy; the story of the neurasthenic usually suffices 
to make the diagnosis. The difficulty lies in 
overlooking some organic disease of which the 
neurasthenia may be symptomatic. A diagnosis 
of simple neurasthenia is never justified until all 
o "ganic conditions have been investigated. Actual 
hypochondriasis and melancholia are to be differ- 
entiated. 
Prognosis.-The prospects in neurasthenia are 
commonly good if the patient is below the age of 
40 years and can be properly controlled and man- 
aged. This, however, is sometimes very difficult 
to accomplish, as circumstances may preclude that 
avoidance of fatigue and interruption of occupa- 
tion usually necessary. If of a psychopathic stock, 
pronounced mental enfeeblement may occur, and 
should be apprehended. Occurring in patients 
before the age of 20, nervous prostration is likely 
to yield more or less readily, and to relapse fre- 
quently. After 40 the prognosis is less hopeful, 
as the neurasthenic exhaustion appears to have 
taken place in tissues that have lost their elasticity 
and recuperative powers, and complete recovery 
after this age is very exceptional. Cases of ex- 
treme emaciation often respond admirably to 
treatment, while some of the most inveterate in- 
stances do not present any considerable physical 
disorder. The presence of organic disease modi- 
fies the outlook in proportion as it is or is not 
manageable. 
Treatment.-There is but one treatment for 
neurasthenia, and that is rest. Whatever func- 
tion or quality of the individual has been overtaxed 
must be allowed an opportunity for recuperation. 
This is more easily said than accomplished. In 
cases of simple neurasthenia in women the Weir 
Mitchell rest cure usually is well advised, and often- 
times secures brilliant results. In men it is scarcely 
practicable, and usually fails when attempted. 
A change of scene, of atmosphere, freedom from 
suggestive surroundings, undue sympathy, and of 
well-meant but harmful solicitude, are generally 
of the first importance. The patient needs en- 
couragement and all the hopeful suggestions that 
can in any way be brought to bear. In proper 
sanitariums this can be provided for the severe 
cases. In milder cases one should give up half his 
daily work, lie abed late in the morning, go to bed 
early at night, take a nap in the middle of the day, 
receive small quantities of readily digested food at 
frequent intervals, strengthening applications of 
water in the form of cold spinal douches in the 
morning, and quieting applications of water at 
bedtime in the form of warm baths or packs. In 
addition the patient should drink a considerable 
quantity of water. Neurasthenics, as a rule, shun 
drinking-water. Elimination from the skin, bowels, 
and kidneys is greatly increased by these simple 
measures. Massage, salt baths, alcohol rubs, and 
general frictions serve a very good purpose in some 
cases, being refreshing and strengthening. Many 
patients who are greatly troubled with insomnia 
promptly drop off to sleep after a half-hour's 
gentle massage. Many of these patients need to see 
the physician frequently: the reiterated encourage- 
ment of the trusted adviser is often of more benefit 
than all other measures combined. 
Office treatment in mild cases, by the use of one 
form or another of electricity, hypodermic in- 
jections of small doses of strychnin or of plain 
water, the use of dry cups, or any other means 
which serves to fix the attention of neurasthenics 
and give a helpful turn to their thoughts, may be 
properly used with the full understanding on the 
part of the physician of its suggestive value. 
Patients should not be allowed to constantly dis- 
cuss their symptoms and fears with members of 
their family or any one else, and it is essential to 
provide for them a certain amount of recreation, 
which is not at the same time fatiguing. It is 
highly injudicious to advise a neurasthenic to ride 
horseback or a bicycle, or to attempt to turn the 
mind from his ailments by a course of reading or 
study. A vacation, with a change of air and scene, 
or a sea voyage, often answers perfectly in mild 
cases. 
In the anemic and emaciated and severe cases 
the scale is the best index as to the success of treat- 
ment. A gain of a pound or so is most encourag- 
ing. The question of diet is, therefore, of ex- 
treme importance. Keeping in mind the gastro- 
intestinal atony, it is necessary to supply food in a 
form that is easily assimilated and least liable to 
fermentation. Many of these patients will digest 
a small amount of food thoroughly, while double 
the amount will cause extreme distress. There- 
fore small quantities of food, particularly of the 
sorts that are easily digested, should be frequently 
administered. 
The drug treatment of neurasthenia may be 
practically dismissed with a word. Large doses of 
strychnin should be condemned. Occasionally a 
hypnotic to reestablish the sleep habit may be 
given with decided advantage. The hypnotic 
should be selected with a view to its being in force 
at the time the restlessness is most prominent. If 
the warm bath and a glass of hot milk or of malted 
milk, or even of hot water, does not suffice to put 
the patient to sleep, a pint of beer, with a hot bath, 
may have the desired result. Should this fail, 
10 grains of trional 2 hours before bedtime may 
be given. If the patient goes to sleep readily but 
wakes up after midnight, trional may be given in a 
dry powder at bedtime. Bromids, chloral, and 
opiates are to be avoided. Gastric disturbance NEURITIS 
may sometimes be relieved by subgallate of bis- 
muth, small doses of calomel, beta-napthol, or 
other -antiseptic preparations which inhibit fer- 
mentation. Constipation must be controlled. 
As a rule, the physician will best succeed in man- 
aging cases of neurasthenia in proportion as he un- 
derstands their mental requirements and can, by a 
vigorous personality, override their fears and con- 
trol their actions, thereby securing for them the 
curative rest which is partial or absolute in pro- 
portion to the severity of the disorder. 
NEURITIS.-An inflammation of the nerve- 
trunks; characterized by pain and paresis of the 
parts supplied by the affected nerve-trunk. 
Etiology.-Wounds and injuries or compression 
of nerves; cold and damp; syphilis; lead. 
Symptoms.-The onset may be accompanied by 
febrile reaction. The most decided symptom is 
pain along the course of the nerve-trunk and its 
peripheral distribution, of a burning, tingling, 
tearing, intense character, increased by pressure 
or motion. If the affected nerve is a mixed one- 
sensory and motor-spasmodic contractions and 
muscular cramps occur, followed by impaired 
motion, terminating in paresis of the muscles in- 
nervated by the affected trunk. If the inflamma- 
tion proceeds to the destruction of the nerve-trunk, 
wasting and degeneration of the muscular tissue 
ensue. Various trophic changes also occur, such 
as cutaneous eruptions and clubbing of the nails. 
The electrocontractility is impaired or lost. 
Diagnosis.-Myalgia or muscular pain is not 
associated with paralysis, nor does the pain follow 
the course of a nerve-trunk. In neuralgia there 
is pain, but, as a rule, no tenderness. In fact, it is 
relieved by pressure. See Neuralgia. 
Prognosis is generally favorable with proper 
treatment. 
Treatment.-Repeated blistering along the 
course of the nerve, with full doses of potassium 
iodid, are usually successful. Sodium salicylate, 
phenacetin, and antifebrin are each of utility. As 
the more acute symptoms subside, the use of gal- 
vanism or a feeble, slowly interrupted faradic 
current restores the disordered function of nerve 
and muscle. 
NEURITIS, MULTIPLE. (Polyneuritis, Kor- 
sakow's Psychosis, Peripheral Neuritis).-A paren- 
chymatous inflammation of a number of symmetric 
nerves, simultaneously or in rapid succession; 
characterized by pain, numbness, loss of power, or 
ataxia, with muscular atrophy. Mental symptoms 
are often associated. 
Etiology.-Alcoholism; syphilis; malaria; lead, 
arsenic, or silver; following diphtheria, typhoid 
fever, and rheumatism. Beri-beri and kakk6 are 
epidemic varieties of multiple neuritis and the 
result of a special poison. See Beri-beri. 
It is likely that the various causes named de- 
velop in the blood a poison, having a particular 
susceptibility or selective action for nerve-fibers. 
Symptoms.-The affection is generally bilateral 
and symmetric. An important characteristic is its 
peripheral distribution, the inflammation being 
most intense at the extremities of the nerves, 
lessening progressively toward the center, usually 
NEURITIS, MULTIPLE 
terminating before the nerve-roots are reached. 
The inflammatory process affects the nerve-fibers 
primarily and the sheath and connective tissue 
secondarily-a parenchymatous inflammation. 
The affected muscles are paler and smaller than 
normal, the fibers reduced in size and undergoing 
granular changes. 
All plans suggested for classifying the varieties 
of multiple neuritis are imperfect. The onset may 
be sudden, even overwhelming, causing rapid 
death, but is usually subacute or chronic in its 
course, the symptoms being wide-spread in pro- 
portion to the acuteness, intensity, and cause of the 
malady. The symptoms may be described under 
three forms-a motor, a sensory, and an ataxic 
form. 
The motor form shows motor weakness, chiefly 
involving the flexors of the ankles, the extensors 
of the toes, and the extensors of the wrist and 
fingers in the forearms. Inflammation of the 
anterior tibial or peroneal nerve in the leg, and the 
radial branch of the musculo-spiral in the arm, 
results in the double "wrist-drop" and "foot- 
drop" so characteristic of this disease. Any 
nerves of the body may be affected, the symptoms 
varying with the particular nerves. 
The sensory form shows pains, tenderness, 
tingling, and numbness, with loss of cutaneous 
sensibility. 
The ataxic form shows incoordination with or 
without sensory disturbances, but with loss of the 
muscular sense. 
The forms may all be associated, in greater or 
less extent, in any one case. Muscular atrophy 
begins early and progresses with the disease. The 
knee-jerk is feeble or absent. The electrocon- 
tractility is feeble or lost. In alcoholic cases 
there may be delirium, mania, and delusions, 
associated with tremors. Trophic changes may 
occur in the nails, hair, and skin. The charac- 
teristic glossy condition of the skin, with some 
edema, is due to involvement of the vasomotor 
nerves. Rarely the vagus, optic, and laryngeal 
nerves are involved. The disease may be ushered 
in with fever, 101° to 103° F., rapid, feeble pulse, 
headache, nausea, vomiting, with delirium or con- 
fusion. 
The alcoholic variety affects chiefly all the limbs; 
the malarial, the legs; diphtheritic, the pharyngeal 
and motors of the eye; rheumatic, the face; and 
lead, the arms. 
Diagnosis.-Early diagnosis is most important, 
as prompt treatment may prevent idleness and 
months of suffering. Since the symptoms of this 
wide-spread affection have been properly separated 
from diseases of the spinal cord, with which they 
were formerly always associated, the diagnosis is 
very readily determined. The distinctive features 
are symmetric localization of the sensory and 
motor symptoms first and mainly in the extremi- 
ties, and the tenderness of the skin, nerve-trunks, 
and muscles. The disease may be confused with 
rheumatism, neuralgia, tabes dorsalis, polio- 
myelitis, and other spinal diseases, and hysteric 
palsy. 
Prognosis.-The earlier the treatment is insti- NEUROMA 
NEW-BORN INFANT 
tuted, the better the prognosis. At best, months 
are required for recovery and even years may be 
necessary. Involvement of spinal cord precludes 
total recovery. The return of faradic irritability 
in nerve and muscle is favorable. To sum up 
with Gowers: "The prognosis is better in the 
sensory than in the motor form; better when the 
arm escapes than when all the limbs are involved; 
better in cases of chronic than acute onset; and 
better if a case of apparently acute onset is really 
such than if it succeeds slight symptoms of longer 
duration." 
Treatment.-The removal of the cause, if possi- 
ble, is a primary step in treatment. Along with 
this, rest is most important, and the rest should 
be complete-in bed. Alcohol should not be 
allowed, although in cases of great debility its 
gradual withdrawal may be justified. The 
patient should, on the other hand, be fed on the 
most nutritious food. Local anodyne applications 
may be resorted to to relieve the pain, and may 
be varied according to effect. Dry heat, moist 
heat, applications of lead-water and laudanum, 
and ointments of aconite and veratrin are some of 
those which may be employed. Wrapping the 
parts in cotton or wool is sometimes beneficial. 
Warm baths are soothing; sometimes very hot 
ones give relief. Postures assumed because of 
the relief they give to pain should not be too long 
permitted, lest deformity result by contractions 
and adhesion difficult or impossible to overcome. 
Dropping of the feet should be prevented by 
splints or by the support of sand-bags. The same 
is true of flexion at the knee and hip. 
As to drugs, they are of little use; the salic- 
ylates, phenacetin, antifebrin, and antipyrin 
may be useful in mild cases, and should be tried 
in doses of 5 to 15 grains. They are more particu- 
larly useful in cases due to cold Extreme pain 
may demand the cautious use of morphin hypo- 
dermically in doses of 1/6 to 1/3 of a grain com- 
bined with 1/150 of a grain of atropin, which 
modifies and improves the action of morphin most 
happily. For the mental symptoms, the hydro- 
bromid of hyoscin in doses of 1/200 to 1/100 of a 
grain hypodermically, or hyoscin in doses of 1/400 
to 1/150 of a grain may be tried. Mercurials, so 
highly approved of in simple neuritis, are useless 
here. The iodids are sometimes beneficial in 
chronic cases. Roborant medicines, such as iron 
and cod-liver oil, are indicated to build up the 
patient, who is generally broken down. Elec- 
tricity and massage are very useful after conva- 
lescence has set in (Tyson). 
NEUROMA.-A tumor of or on a nerve. Many 
a neuroma is really a fibroma. See Tumors. 
NEVUS (or Naevus).-A mark or blemish due to 
dilatation of the blood-vessels near the surface of 
the skin or within its texture. 
Naevi often grow with marked rapidity, and, 
though rarely causing fatal hemorrhage, occasion 
serious inconvenience and great disfigurement. 
Sometimes they spontaneously disappear, but 
more often remain stationary. Cystic degenera- 
tion or suppuration may occur. Microscopically, 
a naevus is composed of large capillaries, arterial 
and venous trunks of larger size, connective 
tissue, fat, and sometimes sweat- or sebaceous 
glands. Inflammation of a naevus generally leads 
to a spontaneous cure. Hence, the injection of 
carbolic acid is used in the treatment of naevi. 
But there is danger of an irritating fluid entering 
a large vessel and passing to the heart, setting up a 
coagulation causing instant death. Ligation, 
pressure, application of caustics, such as fuming 
nitric acid, electrolysis, puncture with the actual 
cautery, and complete excision of the mass, are 
also employed in removal. A capillary naevus 
may quickly be cured by touching it once or twice 
with fuming nitric acid. A knitting-needle at a 
dull red heat or the galvanocautery may be 
employed. Sodium ethylate, in 5 percent solu- 
tion, applied by a glass rod on 2 or 3 successive 
days, has been used to destroy the growth. The 
best plan for the cure of the cavernous variety is 
excision. Astringent injections are not advised. 
Naevus Pigmentosus (Pigmentary Mole).-Cir- 
cumscribed pigmentary deposit, usually congenital, 
with or without associated hypertrophy of other 
cutaneous structures. A "mole" may consist 
merely of a circumscribed deposit of pigment, 
or there may be, in addition, hypertrophy of the 
papillae, of the hairs, and of the connective tissue. 
Naevi vary in size from a pea to the palm of the 
hand or larger, are rough or smooth, elevated or 
nonelevated, and of a brownish or blackish color. 
According to the cutaneous structures involved, 
various forms of pigmentary naevi are distinguished. 
Ncevus spilus is a term given to a smooth, flat, 
pigmented naevus devoid of hair. 
Noevus pilosus is a pigmented naevus covered ■with 
a growth of downy or stiff hairs. 
Noevus verrucosus is a pigmented naevus with an 
irregular or wart-like surface. 
Ncevus lipomatodes is an elevated pigmented 
naevus with connective tissue and fat hypertrophy. 
The etiology is obscure. Hairy moles are 
usually congenital; nonhairy ones acquired. There 
is increased pigment deposit in the cells of the rete 
mucosum and also in the corium. In naevus 
verrucosus the papillae are greatly hypertrophied. 
There is often more or less connective-tissue 
hypertrophy. 
Treatment.-The growths may be removed by 
means of the knife, caustics, or electrolysis. The 
last named is particularly useful in the treatment 
of hairy moles. 
NEW-BORN INFANT.-As soon as the child is 
born it should be held by the feet, with the head 
down, and, with the little finger introduced into 
the mouth, any foreign material that may obstruct 
the air-passages should be removed. 
As soon as pulsations in the cord cease, it 
should be ligated with an aseptic ligature, about 
two fingers' breadth from the abdominal wall. 
An ordinary surgeon's knot, reinforced by a 
double bow-knot to permit tightening after the 
child has had its bath, should be used for this 
purpose. The cord should now be cut, the free 
end being allowed to drain into some convenient 
receptacle. 
Asphyxia Neonatorum.-If the child is born NEW-BORN INFANT 
asphyxiated, the cord should be ligated and cut 
immediately, and all mucus extracted from the 
throat and fauces. 
If the case is of minor degree, stimulation of the 
reflexes will be sufficient to establish normal respi- 
ration. This is best accomplished by slapping the 
buttocks and back of the child with the end of a wet 
towel, by pouring a few drops of ether on its abdo- 
men, or by immersing its back and extremities in 
warm water and pouring ice-water on its epigas- 
trium. The faradic current, if it can be obtained, 
is a very powerful stimulant. Inasmuch as shock 
is a factor of considerable importance in this 
condition hot saline infusion into the rectum or 
hypodermics of strychnin (1/200 grain) or brandy 
(5 to 6 drops) are indicated. In advanced as- 
phyxia artificial respiration should be resorted to 
immediately. The best methods are Schultze's 
and mouth-to-mouth insufflation. 
Schultze's Method.-The child is seized by the 
shoulders from behind with both hands, in such a 
way that the right index-finger of the operator is 
in the right axilla of the child from behind forward, 
and the left index-finger in the left axilla, the 
thumbs hanging loosely over the clavicles. The 
other 3 fingers hang diagonally downward along 
the back of the thorax. The operator stands with 
his feet apart, and holds the child as described, 
practically hanging on the index-fingers in the 
first position, with the feet downward, the whole 
weight resting on the index-fingers in the axiltee, 
the head being supported by the ulnar borders of 
the hands. This is the first inspiratory position. 
At once the operator swings the child gently 
forward and upward. When the operator's 
hands are somewhat above the horizontal the child 
is moved gently, so that the lower end of the body 
falls forward toward its head. The body is not 
flung over, but moved gently until the lower end 
rests on the chest. In this position the chest and 
upper end of the abdomen are compressed tightly. 
The child's thorax rests on the tips of the thumbs 
of the operator. As a result of this forcible expi- 
ration, the fluids usually pour out of the nose and 
mouth of the infant. The child is allowed to rest 
in this position (the first expiratory position) 
about 1 or 2 seconds. The operator gradually 
lowers his arms, the child's body bends back, and 
he again holds the infant hanging on his index- 
fingers with its feet downward; this is the second 
inspiratory position. The movements are repeated 
15 to 20 times in the minute. 
Mouth-to-mouth insufflation is performed as 
follows: Wrap the child in a towel and lay it upon 
its back on a table or chair, with the head well 
extended. This is best accomplished by placing 
a drinking-mug or similar article under the child's 
neck. Place a piece of clean gauze over its mouth; 
take a quick inspiration and blow lightly through 
the gauze. The lungs will immediately become 
inflated. Secure expiration by compressing the 
chest and flexing the head. This should be re- 
peated 15 or 20 times to the minute until the 
child breathes naturally. A very good plan is to 
alternate the foregoing methods, using one for 3 or 
4 minutes and then substituting the other. Efforts 
at resuscitation should be continued until the child 
breathes freely or until the heart stops beating. 
Other methods are as follows: 
Byrd's (H. L.) Method.-The physician's hands 
are placed under the middle portion of the child's 
back, with their ulnar borders in contact and at 
right angles to the spine. With the thumbs ex- 
tended, the two extremities of the trunk are carried 
forward by gentle but firm pressure, so that they 
form an angle of 45 degrees with each other in the 
diaphragmatic region. Then the angle is reversed 
by carrying backward the shoulders and the nates. 
Laborde's Method.-Rhythmic tractions are 
made upon the tongue in order to excite the 
respiratory center. The tongue, covered with 
gauze, is drawn out by the fingers and allowed to 
fall back again 15 to 30 times a minute. 
Dew's Method.-The infant is grasped in the left 
hand, allowing the neck to rest between the thumb 
and forefinger, the head falling far over backward. 
The upper portion of the back and scapula? rest in 
the palm of the hand, the other 3 fingers being 
inserted in the axilla of the babe's left arm, raising 
it upward and outward. The right hand grasps the 
babe's knees, and the lower portion of the body is 
depressed to favor inspiration. The movement is 
reversed to favor expiration, the head, shoulders, 
and chest being brought forward, and the thighs 
pressed upon the abdomen. 
Forest's Method.-The child is placed on its face 
and quick, violent pressure is made on the back; 
then it is placed in a pail of hot water, and the 
hands carried upward until the child is suspended 
by its arms, and mouth-to-mouth insufflation is 
practised; the arms are then lowered and the body 
doubled forward; these movements are repeated at 
the rate of 40 a minute. 
Pacini's Method.-The child lying on its back, 
the operator stands at its head and grasps the 
axillae, pulling the shoulders forward and upward 
to compress the thorax, and allowing them to fall 
in order to expand the chest. 
Schroeder's Method.-The babe, while in a bath, 
is supported by the operator on the back, its head, 
arms, and pelvis being allowed to fall backward; a 
forceful expiration is then effected by bending up 
the babe over its belly, thereby compressing the 
thorax. 
Sylvester's method may be used, the head being 
supported and the feet held firmly by an assistant. 
Recently, the pulmotor has been modified so as 
to be of service in cases of asphyxia neonatorum. 
See Artificial Respiration; Pulmotor. 
Eyes.-Wash the eyes with clean warm water, 
and drop on the cornea of each eye one drop of a 
one or two percent solution of silver nitrate. See 
Conjunctivitis (Ophthalmia Neonatorum). 
Bathing.-As soon as the third stage of labor is 
completed and the mother has been made com- 
fortable, the child should be cleansed. It should 
first be anointed freely with sweet oil to remove the 
vernix caseosa, and then washed with soap and 
warm water. The nurse should avoid the eyes 
during this procedure, since the slightest amount 
of soap or dirty water coming in contact with them 
may produce an ophthalmia. Subsequently the 
NEW-BORN INFANT NICOTIN 
NIGHT-SWEATS 
child should receive a daily bath. The tempera- 
ture of the bath should be about 90° F. Appro- 
priate precautions should be made to prevent the 
child from being chilled when it is removed from 
the bath. 
Cord.-The cord should now be examined 
closely. If the ligature has become loosened, 
the bow-knot should be undone, and a firm sur- 
geon's knot substituted. The cut end of the cord 
should be dusted freely with a powder composed of 
salicylic acid and starch-1 part of the former to 
5 of the latter. It should then be dressed with 
salicylated or borated absorbent cotton and kept 
as dry as possible, and the binder applied. At its 
subsequent daily baths the cord should be 
closely inspected and fresh powder and dressing 
applied. 
Clothing.-An infant should be clothed as 
follows: A binder of soft flannel, a diaper, a knit 
shirt, and knit woolen shoes. Over these should 
go 2 skirts. These should be suspended from the 
shoulders. Finally should come its dress. During 
the winter a knit jacket may be worn over the dress, 
and, particularly if the child is subject to attacks of 
coryza, a cap is desirable to protect it from drafts. 
The child should have an abundance of diapers, 
which must be changed from 16 to 24 times daily. 
To prevent chafing, perfect cleanliness must be 
maintained and some dusting-powder, like lyco- 
podium or compound talcum, used. 
Nursing.-During the first 48 hours the child 
should be put to the breast regularly every 4 
hours. The colostrum that it receives from the 
breast acts as a mild laxative and secures free 
evacuation of the meconium in the child's intes- 
tinal tract. After the milk appears, it should be 
put to the breast every 2 hours during the day, and 
2 or 3 times at night. This interval should gradu- 
ally be lengthend until at the end of about the 
third month it is nursed every 3 hours during the 
day and once or twice at night. See Infant 
(Care), Infant Feeding, etc. 
NICOTIN.-C10HuN2. A poisonous alkaloid 
found in the leaves of the tobacco plant; a color- 
less, oily fluid, of acrid taste and penetrating odor, 
readily soluble in water, and forming soluble salts 
with acids. In tetanus and strychnin poisoning 
the dose is 1/20 to 1/10 minim in 2 hours. The 
proportion of nicotin in tobacco is about 1:1700. 
Turkish tobacco contains little or none. It is an 
open question whether or not there is more nicotin 
in tobacco before or after curing. Nicotin, even 
in minute doses (1/7 of a grain), causes symptoms 
of gastric irritation, with an extreme degree of 
collapse, abolishing the function of motor nerves 
and paralyzing respiration. A dose of 1/15 grain 
has caused death in a human being. For the 
depression due to excessive smoking, 1 to 2 drams 
of Hoffmann's anodyne, or the spirit of nitrous 
ether, is effective. Strychnin is the best physi- 
ologic antidote to nicotin. 
The treatment of poisoning by nicotin consists 
in the use of strychnin, the employment of car- 
diac stimulants, external heat, and atropin, while 
the stomach should be evacuated, tannin, the 
iodids, and artificial respiration employed. See 
Tobacco; and Lambert's Treatment for Nar- 
cotic Addiction. 
NICTITATION.-Clonic spasm of the orbicularis; 
and is really frequently repeated involuntary 
winking. It may be associated with hysteria, 
chorea, or general neurasthenia; in fact, it may 
be a symptom of nearly any reflex neurosis. It 
often becomes a habit. Clonic spasms of the 
orbicularis sometimes appear after the use of 
eserin. In persons doing considerable eye-work, 
there is doubtless some uncorrected error of refrac- 
tion. The treatment of this condition consists in 
administering remedies alleviating the nervous 
condition, or in correcting the ametropia. 
NIGHT-BLINDNESS.-See Hemeralopia. 
NIGHTMARE.-A feeling of distress or suffoca- 
tion during sleep, attended by fright, hideous 
dreams, and often by inability to stimulate muscular 
contraction, except in the slightest degree. A heavy 
meal or indigestible food has generally been taken 
before the sleep, and this is especially so in those of 
a nervous temperament, whose digestion is weak. 
Eye-strain sometimes causes night-terrors. A 
closely allied condition occurs as a consequence 
of brain-exhaustion, and in those whose sleep has 
continually been broken in consequence of over- 
work, by application to study, business details, or 
literary pursuits. Certain forms of incipient 
delirium are akin to it, such as occur in various 
febrile diseases or as a result of alcoholic excesses. 
Treatment.-The didt should be light, and late 
meals and indigestible food avoided. A teaspoon- 
ful of camphor water, repeated if necessary, may 
be the best remedy. For the nightmare of adults 
potassium bromid in small doses may be admin- 
istered. In the attacks of night-screaming of 
children the digestive organs are frequently at 
fault, although they are sometimes associated 
with worms and delayed dentition. The moral 
surroundings of children so affected should be 
closely studied. Ghost stories and appalling tales 
should be discontinued. Indigestion is to be 
treated by a few grains of sodium bicarbonate and 
powdered rhubarb. Forbidding potatoes, candies, 
puddings, fruit, and cake may have a salutary 
effect. Potassium, sodium, and ammonium bro- 
mids are probably the best means of preventing 
future attacks. Sulphonal, chloral, or trional 
may also be given. Punishment, cold douches, 
or treatment adding to the distress are to be 
condemned. During the attack, efforts should 
be made to soothe the child and calm its fears by 
assurances of present safety. 
The following mixture may be given every night 
at bedtime to a child of 1 year: 
1$. Ammonium bromid, 
Sodium bromid, 
Wine of antimony, 
each, 5 ss 
Simple syrup, 5 j 
Peppermint water, enough for 3 ij. 
Give a teaspoonful at bedtime. 
NIGHT-SWEATS.-The profuse nocturnal 
sweating often observed in pulmonary tubercu- 
losis and other wasting disorders. In tubercu- NIPPLE 
losis of the lung they are one of the most dis- 
tressing features, and may come on early in the 
disease, although they are more persistent and 
frequent after cavities have formed. 
Treatment.-Belladonna, or its alkaloid, atropin, 
is one of the best remedies. It may be given 
internally, or externally as a liniment. It is 
especially beneficial when applied externally to 
children. Atropin, 1/200 to 1/100 grain hypo- 
dermically, or 1/60 to 1/20 grain by the mouth, 
is useful when given about 1 hour before the 
usual or expected time of beginning of sweating; 
duboisin may be used instead. Aromatic sul- 
phuric acid may be used alone, or with belladonna 
or morphin, to check night-sweats, but it creates 
indigestion. Camphoric acid, given dry on the 
tongue, not over 2 hours before the expected 
sweating, is considered one of the very best 
remedies against sweating from various causes, but 
especially that from phthisis when it is very 
profuse. The dose is 10 to 30 grains. Pilocarpin, 
1/20 grain hypodermically, or given in the same 
dose thrice daily by the mouth, may be used to 
check profuse perspiration, even when atropin 
fails. Dover's powder will often check a profuse 
colliquative sweating. Agaricin, muscarin, and 
zinc oxid at bedtime are useful for the night- 
sweats of phthisis. 
I|. Zinc oxid, gr. xxx 
Extract of belladonna, gr. iij. 
Make into 10 pills. Give 1 pill before going 
to bed. 
Tannic and gallic acids, salicin, and ergot are all 
employed. 
Acetic acid, diluted one-half with water, alum 
dissolved in weak alcohol, and naphthol in a 
5 percent alcoholic solution are used locally 
Oleate of zinc and of aluminum may also be used. 
See Tuberculosis. 
NIPPLE.-See Breast (Diseases). 
NITER.-See Ether, Nitrates. 
NITRATES.-The salts of nitric acid. All 
nitrates are soluble in water. A solution called 
acid phenylsulphate, and composed of 46 1/2 
grains of phenol in 5 1/2 drams of strong sulphuric 
acid, is used for the detection of nitrates in water. 
See Water. 
Potassium nitrate, or saltpeter, sodium nitrate, 
and silver nitrate are the most commonly used 
nitrates in medicine. These and the other nitrates 
are described under the metallic titles. They are 
poisonous, and are often taken with suicidal intent. 
Emetics and the stomach-tube should be used, 
and soap in quantity administered. Demulcent 
drinks should follow, and emollient enemata used to 
protect the lining membranes of the intestines. 
Milk may be used with benefit. Of antagonists, 
opium in small doses may be administered for the 
subsequent depression, and aromatics and brandy 
are of value. 
NITRIC ACID.-A colorless, fuming liquid, very 
caustic and corrosive, of strong acid reaction, used 
only externally as a caustic. Its preparations 
are: Diluted Nitric Acid, 10 percent nitric acid, 
given in the dose of 3 to 40 minims, well diluted. 
Nitrohydrochloric Acid or Nitromuriatic Acid 
(aqua regia), a golden-yellow, fuming, corrosive 
liquid, having 18 volumes of nitric acid and 82 
volumes of hydrochloric acid, a drop of which, 
added to a test-solution of potassium iodid, will 
liberate iodin in abundance. Dose, 1 to 8 minims, 
well diluted. Diluted Nitrohydrochloric Acid. 
Consists of nitric acid 4, hydrochloric acid 18, 
water 78. Dose, 5 to 20 minims, well diluted. 
Therapeutics.-Nitric acid does not tend to 
relax the bowels, as does nitrohydrochloric acid. 
It coagulates, but does not redissolve, the albumin 
of the tissues, and thus soon makes a barrier for 
itself. It is used externally to destroy warts, 
chancres, hemorrhoids, phagedenic ulcers, in 
gangrene, etc. For indolent ulcers a solution of 
from 5 to 30 drops to the ounce is of use. In 
oxaluria nitric acid is preferable to the nitromuri- 
atic acid. Three-drop doses of nitric acid are 
beneficial when small ulcers in the mouth or stom- 
atitis exist. In gastric indigestion, intestinal 
dyspepsia, the green summer diarrhea of children, 
and combined with pepsin in the chronic diarrhea 
of children, it is stimulant and astringent. A 
lotion of nitric acid, 1/2 to 1 dram to a pint of 
water, is of service in bleeding hemorrhoids. The 
dilute acid should be taken through a glass tube 
to protect the teeth. 
In cholera morbus: 
I). Nitric acid, 3j 
Tincture of opium, gtt. xl 
Camphor water, 5 viij. 
Give one-fourth part every 3 or 4 hours. 
Nitrohydrochloric acid is an efficient cholagog, 
and is employed with benefit in jaundice, dys- 
pepsia, the so-called bilious condition, and also in 
acidity of the stomach. The official dilute acid 
rapidly deteriorates, and the strong acid also is 
unstable. It is best to use only the strong acid 
freshly prepared, which is of an orange-red color. 
This should be constantly protected from light 
and taken well diluted. 
NITRITES.-The salts of nitrous acid, HN02. 
The term is also applied to certain combinations 
with organic radicles, as nitroglycerin, C2H5(NO2)3, 
nitrobenzol, amyl nitrite, and other compounds. 
Physiologic Action.-Amyl nitrite and the other 
nitrites agree closely in their general action, pro- 
ducing great vascular dilatation by paralyzing the 
sympathetic system, the vasomotor center, or the 
muscular coat of the arterioles-which, is yet 
undecided. They cause tumultuous action of the 
heart by relaxing its inhibition; lowered respira- 
tion, from paralysis of the respiratory muscles and 
impairment of the ozonizing function of the blood; 
diminution of sensation, motility, and reflexes; 
a sense of heat, but lowered body-temperature; also 
throbbing pain in the head, beating carotids, 
quickened pulse, flushed face, and vertigo. 
Sodium nitrite is slower in action than amyl nitrite, 
and does not cause so much throbbing headache 
as nitroglycerin. It may be given in solution 
with water. The action of all these agents is 
NITRITES NITROGLYCERIN 
NOCTURNAL EMISSIONS 
probably due to the nitrous acid contained in 
them. Nitroglycerin acts similarly to the nitrites, 
but less promptly, and its action is more enduring. 
The headache it produces is of intensely frontal 
character, and persists for hours after the .other 
effects have passed off. It is more suitable than 
amyl nitrite for internal administration. 
Therapeutics.-Amyl nitrite possesses a peculiar 
fruity odor. It is useful in attacks of angina 
pectoris, asthma, epileptiform convulsions, tran- 
sient hemianopsia, and occasionally in sea-sickness. 
Dose, internally, 1/4 to 1 minim, dissolved in 
alcohol; by inhalation 2 to 5 minims, generally put 
up in glass beads. 
Nitroglycerin is sometimes of benefit in neuralgic 
dysmenorrhea and in sea-sickness; in chronic 
interstitial nephritis; and in hiccup and migraine 
of spasmodic character, and has given immediate 
relief in neuralgia of the fifth nerve and in sciatica. 
In angina pectoris it gives more lasting effects than 
amyl nitrite. In the weak heart of the aged, or 
in that from fatty degeneration, or when, as in 
Bright's disease, arterial tension is above the 
normal, and in irritable and overacting heart, it is 
of service. It is a dangerous explosive, and should 
not be kept in stronger solution than 1 percent. 
Dose, 1/200 to 1/50 minim or more, according to 
susceptibility. 
Sodium nitrite may be used in hemicrania, 
angina pectoris, and in asthma of purely bronchial 
and neurotic origin. In chronic desquamative 
nephritis, with a weak and dilated heart, it is 
useful. By prescribing it with spirit of chloroform 
or ammonia water, and small doses of morphin, 
disagreeable symptoms may be avoided. Dose, 
1/2 to 3 grains. 
Poisoning.-Ergot, belladonna, strychnin, brucin, 
digitalis, picrotoxin, and all other agents which 
increase the functional activity of the spinal 
cord and sympathetic, are antagonistic, though 
by reason of their slower rate of diffusion the 
antagonism may not always be available. Stimu- 
lants, artificial respiration, the alternate cold and 
hot douche, with cold to the head, and ergotin or 
atropin subcutaneously, are the best means to 
be used in cases of poisoning by the nitrites. 
NITROGLYCERIN.-See Nitrites. 
NITROUS ETHER.-See Ether. 
NITROUS OXID.-N2O. Nitrogen Monoxide. 
A gaseous compound known also as laughing gas, 
devoid of odor, but with a slightly sweetish taste, 
which, when inhaled, produces mental exaltation 
and cerebral excitement, followed by anesthesia. 
It is the safest of all anesthetics, but ought not to 
be given to those far advanced in age or having 
atheromatous arteries. It rarely produces any 
disagreeable after-effects, save a slight dizziness 
for a few hours. It is much used in dentistry. 
Its preparation requires apparatus too cumber- 
some for the ordinary practitioner of medicine. 
When first inhaled, the face becomes flushed, then 
of deadly pallor, and the lower jaw may drop; at 
this time anesthesia is complete, and the operation 
should be quickly performed. The gas should be 
administered without access of air, and if so, 
insensibility is usually attained in from 50 to 80 
seconds from the commencement of inhalation. 
The following points are to be studied in the 
administration of nitrous oxid as an anesthetic: 
1. The patient should have a full and free ex- 
pansion of the chest. To obtain this all impedi- 
ments to free chest movement should be removed. 
The head should not be thrown back nor flexed in 
any direction, and the feet should be so placed 
that if violently extended, they cannot come in 
contact with a wall or other fixed point of resist- 
ance. Two hours after a moderate meal is not 
too soon for administration. It may be reinspired 
with safety, when necessary. 
2. The apparatus employed should be of modern 
description, and in good working order. Nitrous 
oxid is supplied in a liquid form, condensed by its 
manufacturers into wrought-iron bottles, whence 
it is liberated into bags from which it is to be in- 
haled. The bag should not be filled within the 
patient's sight, never overfilled, and should rest in 
the patient's lap during inhalation. The bottles 
should be small, duplex, and should both be con- 
nected with the air-bag, so that one may be drawn 
from if the other is exhausted, without delay. 
The screw-plugs in bottles should be turned loose, 
and away from the operator or surrounding per- 
sons. The mask may be of celluloid, and its 
rubber pad should be inflated immediately before 
use. 
3. During administration the mask should fit so 
closely as to allow no admission of air. If it is 
wished to prolong unconsciousness, the mask 
should be lifted up after 6 or 8 full breaths of gas 
have been taken, or signs of anesthetization are 
apparent, so that air may be once more inhaled, 
and more gas then administered, etc. 
4. During, and immediately after, operation care 
is to be exercised against a vigorous inspiratory 
effort drawing materials-blood-clots, portions of 
extracted teeth, or other substances-into the 
larynx. The mouth is to be washed out while the 
head is turned to one side. 
5. If possible, a qualified assistant should be on 
hand to administer the gas, and to guard against 
complications from the possible occurrence of 
erotic delusions in female patients. 
For description of nitrous oxid and oxygen 
anesthesia in major surgery, see Anesthetics 
(General). 
NOCTURNAL EMISSIONS.-Too frequent emis- 
sions reduce the strength, make the patient 
irritable and weak, and gradually prey upon his 
mind. When masturbation is practised, extreme 
mental depression ensues. Nocturnal emissions 
occurring in normal males who are continent 
and chaste are not to be interfered with unless ex- 
cessive. 
Treatment.-Unchaste literature and lascivious 
thoughts are to be avoided. A hard mattress and 
light covering is advisable. Sleeping on the back 
is undesirable. A spool is sometimes tied around 
the loins so that when the sleeper rolls on his back, 
he is awakened by the pressure. Of drugs used to 
prevent the nocturnal emissions, potassium 
bromid, in doses of 20 grains at bedtime, or the 
same amount of chloral, may be taken. Hyoscin NOCTURNAL ENURESIS 
NOSE, DEFORMITIES 
hydrobromid, 1/100 grain, has been recommended. 
Cold sponging of the perineum and loins night and 
morning has been of great benefit. All irritations 
of the bladder or genitourinary system should be 
corrected. Potassium citrate, in doses of 20 grains 
in water 3 times daily, will render the urine un- 
irritating and alkaline, and allay a provocative 
cause of emissions. Arsenic alone or in combina- 
tion with strychnin is often of service when given 
in full dose. Stimulating foods and drinks are to 
be avoided. 
NOCTURNAL ENURESIS.-See Urine (Incon- 
tinence). 
NOMA.-See Stomatitis (Gangrenous). 
NOGUCHI'S TEST.-See Syphilis. 
NOSE-BLEED.-See Epistaxis. 
NOSE, CARIES AND NECROSIS.-Inflammation 
of the bones of the nose, leading to caries and 
necrosis, is usually the result of syphilis, heredi- 
tary or acquired; but it may be due to tubercle or 
glanders, to injury, the presence of foreign bodies, 
septic decomposition, mercury, and occasionally 
the fumes of bichromate of potassium. The 
septum may be attacked, so that the bridge of the 
nose sinks in (although, in an adult, a great deal 
may be lost without any apparent alteration in 
shape), or the turbinate bones, or the roof, and 
in the latter case there is always the risk of 
meningitis. 
The symptoms are those of inflammation of the 
mucous membrane, but the discharge is always 
profuse and fetid, the breath exceedingly foul, and 
nothing, so long as any dead bone exists, gives 
more than temporary relief. In many cases the 
diagnosis is clear at once; either there is a perfora- 
tion of the hard plate, or a probe introduced into 
the nasal cavity strikes the sequestrum at once; 
but sometimes, especially when it lies toward the 
upper and back part, detection is a matter of very 
great difficulty. 
Treatment.-The dead bone must be removed as 
soon as it is loose, careful attention being paid at 
the same time to any constitutional taint that is 
present. In most cases it can be extracted, under 
an anesthetic, through the anterior nares; some- 
times it is easier to push it back into the pharynx 
(the two forefingers can usually be made to meet 
in the inferior meatus of the nose, the one intro- 
duced from the front, the other from behind, when 
the patient is anesthetized), but the operator must 
be prepared for free, though not usually serious, 
hemorrhage. When, owing to the size of the 
fragment, this cannot be done, Rouge's operation 
may be performed-i. e., an incision made through 
the mucous membrane, where it is reflected from 
the under surface of the upper lip on to the gum, 
the cartilaginous septum detached from the 
anterior nasal spine, and, if necessary, from the 
maxillary crest; the alae detached at the margins, 
and the upper lip with the nose lifted up and re- 
flected on to the forehead. The nasal cavities are 
thoroughly opened up to view by this, the whole 
interior can be examined, and then the nose and 
lip replaced without a suture being required or a 
mark left. If the dead bone, without being loose, 
is fairly accessible, as frequently happens in hered- 
itary syphilis, it may be partially dissolved away 
by a sulphurous acid spray (which also helps to 
check the fetor), and occasionally can be chipped 
off in little pieces with a fine chisel, but care must 
be taken that the instrument does not slip and 
penetrate the roof. See Rhinitis (Chronic). 
NOSE, CATARRH.-See Rhinitis. 
NOSE, DEFORMITIES.-Congenital malforma- 
tions are rare; deformities, on the other hand, 
resulting from injury, lupus, or syphilis, are very 
common. 
Deviations of the septum, if causing severe symp- 
toms, may be straightened by means of forceps or 
operation, but the tendency to return is often so 
great that either the process must be repeated 
again and again, or an intranasal splint must be 
worn for some time. 
Extensive destruction of the soft parts can some- 
times be remedied by means of a plastic operation; 
but in cases in which it is due to disease, this should 
never be attempted until the stump is perfectly 
sound. 
The two best known methods of rhinoplasty are 
the Indian, and that first carried out by Tag- 
liacozzi (the Italian). In the former a flap of 
suitable shape is marked out upon the forehead, 
having its pedicle immediately over the root of the 
nose, or slightly to one side, so that it can be 
twisted down more easily. This is carefully 
dissected up [Langenbeck recommends that the 
periosteum should be brought away with it], ad- 
justed in a bed prepared for it by cutting away the 
old scar-tissue around the margins of the orifice, 
and secured with sutures, hollow plugs being in- 
serted into the nostril, so that it may retain its 
shape. To avoid the sinking inward of the tip, 
Lagenbeck reflected some of the bony margin of 
the nostril, fashioning a flap from each side, so that 
they should meet like the rafters of a roof in the 
middle; but when the nose has been destroyed by 
inflammation, this proceeding is rarely practicable. 
In the Italian method the skin is taken from the 
arm over the biceps. In the original plan the flap 
was raised by an incision down each side and left to 
granulate; then the upper end was separated; and, 
after the skin, detached now on 3 sides, had begun 
to shrink, it was carefully fixed by sutures in the 
freshly cut margins of the defect. The arm is fixed 
with plaster bandages in a suitable position, and 
must be so retained without the slightest traction 
for at least 8 days. The treatment has since been 
shortened by detaching the flap at an earlier date, 
but naturally with some risk. Of these two meth- 
ods there is no doubt that the former is the better 
when it is practicable, in spite of the scar it 
leaves. In the latter the transplanted flap sinks 
into a shapeless mass. Neither, however, is really 
satisfactory, and it is probable that in most cases 
the deformity would be better concealed by an 
artificial nose made from vulcanite or enameled 
silver and fastened on to the spectacle-frame. 
In cases in which one ala only is defective, Lang- 
enbeck's plan of reflecting a flap from the other on 
the opposite side (leaving it attached by a bridge 
upon the dorsum) tends to diminish, or at least 
equalize, the deformity. There is, however, some NOSE, DISEASE OF THE ACCESSORY SINUSES 
difficulty in separating the skin from the cartilage 
without cutting or bruising it, owing to the very 
close connection that exists between the two. See 
Plastic Surgery. 
meatus will be again full. When it does not escape 
the signs of tension are more marked. 
Transillumination of the upper jaw serves to 
confirm this. The patient is seated in a dark 
room, or is examined under a photographer's cloth, 
supported by an umbrella. A small electric 
lamp is placed in the mouth and the lips closed, 
when a dull glare will illuminate the sound cheek 
and pupil, leaving the pupil on the diseased side 
and the infraorbital region partly in shadow. 
With eyes closed the patient experiences a dull red 
glow in the eye of the sound side, which is absent 
on the diseased side. It is this unequal illumi- 
nation of the two sides which is important for 
diagnosis. 
If neglected, the empyema may burst on the 
cheek or lead to necrosis of the upper jaw, or there 
may be septic absorption resulting in pyemia; or 
septic thrombosis of the orbital veins may occur, 
producing proptosis or acute optic neuritis; or the 
NOSE, DISEASE OF THE ACCESSORY SINUSES. 
Empyema of the Maxillary Antrum. 
This sinus is an air space in the upper jaw lined 
with thin mucous membrane and communicating 
with the middle meatus of the nose by an open- 
ing about one inch above its floor. Into the floor 
project the roots of the molar teeth, which are 
separated by only a very thin plate of bone; but 
the roots of any of the teeth in the upper jaw may 
communicate with it. 
Empyema of the antrum is a collection of muco- 
pus prevented from escaping into the nose owing 
to the orifice being obstructed, or owing to the 
fact that it is above the level of the floor. The 
empyema may form in course of an acute inflam- 
mation, especially during influenza, or may occur 
i.t, m.t, s.t. Inferior, middle and superior turbinals, 
m.a, Maxillary antrum opening into middle turbinal fossa. 
f.s, Frontal sinus and infundibulum, into which open anterior 
ethmoidal cells, s.s, Orifice of sphenoidal sinus, o, Infra- 
orbital canal. Arrows show the points at which the antrum 
is punctured.-(Spencer and Gask.) 
The Maxillary Antrum. 
as a subacute affection by extension from a dental 
alveolus, and less commonly from necrosis of bone; 
or it may be a mere chronic retention, owing to the 
orifice being blocked by nasal polypi. An em- 
pyema may rarely be the result of an acute osteo- 
myelitis of the walls of the maxillary antrum, set 
up by septic inflammation in the mouth, such as 
cancrum oris, or it may follow gonorrheal con- 
junctivitis. 
The signs are neuralgic pain and inflammatory 
swelling of the cheek, with fever. Pus may escape 
from the nose, pale yellow, intermittent in its flow, 
and its odor will then be perceived, especially by 
the patient; whereas in atrophic ozena the patient 
may be unconscious of the foul odor, so evident 
to bystanders. It flows when the patient's head 
is bent forward, or may be directed backward 
into the pharynx and disturb the patient's appe- 
tite. The interior of the nose should be wiped free 
of pus, and the patient's head bent, after which the 
Puncture of the Maxillary Antrum through the 
Canine Fossa.-(Spencer and Gask.) 
thrombosis may extend further back to the 
cavernous sinus and brain, setting up meningitis. 
Treatment.-Cocain is applied to the inferior 
meatus and then a trocar and cannula is pushed 
through the wall into the antrum. If pus escapes 
the cannula can be kept in or it is replaced by a 
tube and the antrum frequently irrigated. Or 
the hole may be enlarged under gas at the same 
time that the anterior end of the inferior turbinal 
is removed. This provides an opening level with 
the floor of the antrum which shows no tendency to 
close, and through which the antrum can be easily 
irrigated by passing a catheter like a eustachian, 
or female urethral catheter. If there are polypi 
to be removed from the antrum, the aperture 
as above is further enlarged by raising the lip 
from the gum so as to expose the lateral nasal wall 
of the superior maxilla which is chipped away until NOSE, DISEASE OF THE ACCESSORY SINUSES 
a finger and a sharp spoon can be inserted. Polypi 
and dead bone are scraped away, but healthy 
mucous membrane is left. After this a plug of 
iodoform gauze is inserted and brought out 
through the nostril, while the communication 
with the mouth is closed by suture. Blood is 
prevented from running back by temporarily plug- 
ging the posterior nares before cutting away the 
turbinal. 
If the disease is dental in origin the antrum may 
be perforated through the canine fossa, and a 
counter-opening made into the inferior meatus 
continuous discharge of pus through the infundib- 
ulum, or the passage of a probe into the infundib- 
ulum may push aside polypoid granulations, and 
be followed by a flow of pus. 
An X-ray examination shows the size of the 
frontal sinus, which varies from a small dilatation 
of the upper end of the infundibulum to one ex- 
tending upward on the forehead and outward 
to the outer angle of the orbit, the sinus of the two 
sides freely communicating. 
Treatment.-A mucocele may be relieved by 
excising the anterior end of the middle turbinal 
bone and also any polypi, then the frontal sinus is 
washed out by passing a cannula. 
An empyema, when the mucous membrane is 
still healthy, may be relieved in the same way. 
If it is of some standing and there is a polypoid 
degeneration of the mucous lining, an incision is 
required. This is an angular one about 1 1/2 
inches in length, through the inner margin of the 
eyebrow down to the bone. The periosteum along 
with the pulley of the superior oblique muscle is 
pushed toward the orbit. Then the floor of the 
frontal sinus is entered at its lowest level through 
the roof of the orbit just behind the inner angle. 
The whole sinus is scraped out including the in- 
fundibulum, and a free communication with the 
nose reestablished. A rubber tube is now cut 
off the length to reach from the upper end of the 
infundibulum to the free margin of the anterior 
nares. To hold it in place a temporary suture is 
Sinuses Opening into the Upper Part of the Nose 
1. Frontal sinus. 2. Infundibulum. 3. Opening of an- 
terior ethmoidal cells. 4. Superior turbinal. 5. Opening 
of posterior ethmoidal cells. 6. Sphenoidal sinus. 7. 
Middle turbinal partly cut away. {Spencer and Gask.) 
of the nose as above; for then the communication 
with the mouth will soon close spontaneously. 
Dental surgeons, instead of making the counter- 
opening, pass a short cannula through the per- 
forated socket of an extracted tooth, the lower end 
of the cannula being fixed in a dental plate and 
closed by a split plug with a knob to facilitate with- 
drawal. This is retained until the mucous mem- 
brane of the antrum has returned to the normal. 
But the objection is that dead bone, polypi, or food 
materials from the mouth may keep up the dis- 
charge indefinitely. 
Mucocele and Empyema of the Frontal Sinuses. 
Mucocele.-Retention of mucus may occur in 
the frontal sinus owing to swelling and hyper- 
trophy of the nasal mucous membrane over the 
middle turbinal, or to the formation or polypi in 
that region. The anterior wall of the sinus after 
a time becomes thinned and a fluctuating swelling 
forms on the forehead to one or both sides of the 
middle line. An acute inflammation of the nasal 
mucous membrane, such as may be set up by 
influenza, may spread up the infundibulum to the 
frontal sinuses, giving rise to an empyema with 
or without an intermittent discharge of pus into 
the nose. 
The symptoms are frontal headache, and when 
there is suppuration, severe frontal pain, also red- 
ness and edema of the forehead and eyefids, and 
later fluctuation and pointing. With this is a 
On the right side is shown the line of the incision; on the left 
side, the opening made into the sinus. {Spencer and Gask.) 
Frontal Sinus Operation. 
inserted at each end of the tube. This enables 
the skin wound to be entirely closed, and so a 
fistula and puckered scar is avoided. 
In the case of a very large frontal sinus some of 
the anterior and inferior wall must be clipped 
away, and then an iodoform plug is required to 
stop the hemorrhage, after the removal of which 
a secondary suturing of the skin can be done. 
Disease of the Ethmoidal and Sphenoidal Sinuses. 
-The ethmoidal sinuses lie along the inner wall 
of the orbit, and a mucocele produces a swelling 
on the inner side of the orbit, which pushes the eye 
outward and causes squint. 
The sphenoidal sinus lies behind in the base NOSE, EXAMINATION 
NOSE, EXAMINATION 
of the skull. The orifice of the sphenoidal sinus 
can be reached by first applying cocain, then passing 
a probe backward and upward across the center 
of the middle turbinal, while the shank of the 
probe is kept in contact with the lower margin of 
the anterior nares. 
Ethmoidal and sphenoidal empyemas give rise 
to deep-seated pain in the orbit and back of the 
nose, with a discharge into the nasopharnx. The 
dangerous complications are septic basal menin- 
gitis and thrombosis of the cavernous sinus. 
Exophthalmos, ptosis, strabismus, retrobulbar 
neuritis, and blindness occur when the nerves at 
the back of the orbit become involved. Treat- 
ment.-Removal of the anterior end of the middle 
turbinal may relieve simple retention. The eth- 
moidal cells may be curetted from the nose, 
regard being had to the nearness of the meninges 
and cavernous sinus. The anterior ethmoidal 
cells are reached through the inner side of the orbit, 
by extending the incision for the frontal sinus a 
little downward. The sphenoidal sinus opening 
is enlarged under the guidance of the prqbe 
passed as above. A general anesthetic may 
be given, a speculum inserted, and a fine cut- 
ting hook is passed in and the orifice enlarged, 
or fine punch forceps may be employed for the 
purpose. (Spencer and Gask.) 
NOSE, EXAMINATION.-This organ con- 
sists of two parts: the external, made up of 
nkin, cartilage, and bone; and the internal, or 
yasal fossae, which communicate with the phar- 
snx posteriorly through the medium of the 
posterior nares. The anterior nares form the 
entrance to the nostrils. Each nostril con- 
tains 3 turbinated bones-the superior, middle, 
and inferior-thus dividing it into the superior, 
middle and inferior meatuses. The whole of 
the internal surface is covered with mucous 
membrane, that on the turbinated bodies being 
easily congested and highly erectile. The por- 
tion covering the lower and anterior portions of 
the middle and inferior turbinated bodies fre- 
quently gives rise to catarrhal inflapimation 
with obstruction of the nasal chamber. Thick, 
viscid mucus is constantly secreted from muci- 
parous and serous glands lining the internal 
surface of the nostrils, which catches foreign 
particles that have been inhaled and also warms 
the air before it reaches the lungs. The nasal 
cavities (choanae) communicate with the eth- 
moid, frontal, and sphenoid sinuses and the 
antrum of Highmore, all of which are lined 
by a prolongation of the nasal mucous mem- 
brane. The superior portion of each nasal 
chamber is supplied by filaments from the 
olfactory nerve and controls the sense of smell, 
while that portion below the lower border of the 
middle turbinated bone may be termed the res- 
piratory portion. 
Anterior Rhinoscopy.-The essentials are: A 
good light, a nasal speculum, a nasal probe, and a 
head-mirror with a central opening. 
The patient should be seated facing the exam- 
iner, and with the light behind or on each side of 
head, and on a level with the eye of the operator. 
After anesthetizing the anterior nares with a few 
drops of a 10 percent solution of cocain, the nasal 
speculum is introduced, and at the same time the 
light is reflected into the nares by means of the 
head-mirror. It is essential for the examiner to 
always look through the central opening of the 
head-mirror rather than from above or below. It 
is best to examine the nares anteriorly, gradually 
going backward until the whole anterior chamber 
has been surveyed. A hypertrophic condition 
can be quickly determined by applying a few 
drops of a solution of cocain (10 percent) to a 
suspected spot by means of a pledget of cotton 
wrapped around the probe, when, if no organic 
change has taken place, the erectile tissue quickly 
contracts and the enlargement disappears. Care 
should be exercised at all times against cocain 
poisoning. 
Posterior Rhinoscopy.-For this are needed a 
tongue-depressor, head-reflector, throat-mirror, 
palate-hook, and throat-applicator. The patient 
should be seated in the same position as for ante- 
1. Nasal septum. 2. Anterior extremity of middle turbin- 
ated bone. 3. Middle meatus. 4. Section of inferior turbinated 
bone. 5. Inferior meatus. 6. Lacrimal canal. 7. Canaliculi. 
8. Nasal canal. 9. Section of reflected mucous membrane. 10. 
Maxillary sinus or antrum of Highmore. 
Transverse Section of Nasal Foss.e. 
rior rhinoscopy. A few drops of a solution of 
cocain (5 percent) are then applied to the upper and 
posterior vault of the pharynx and the palatine 
folds (care being exercised to prevent swallowing 
the fluid), and, after waiting a minute or two, the 
tongue-depressor is inserted in the mouth to a 
sufficient distance to hold the organ down, but not 
sufficiently to cause gagging. The light is then 
directed toward the pharynx, and the mirror, after 
being slightly heated (to prevent it becoming NOSE, FOREIGN BODIES 
NOSE, POLYPS 
cloudy from the moisture during respiration), is 
introduced well back into the pharynx, and, by 
rotating it slightly, the choanae. are surveyed 
thoroughly. Subsequently the lower portions of 
the posterior nares are examined. Directions 
should be given to the patient to breathe natur- 
ally during the examination, otherwise the soft 
palate retracts and closes the posterior orifices. 
In some cases the tongue-depressor causes gag- 
ging, and in these cases the organ may be held 
out of the way by grasping it within the folds of 
a napkin. The examination is often an educative 
one on the part of the patient, and the first trial 
may fail. 
NOSE, FOREIGN BODIES.-Peas, beads, peb- 
bles, beans, marbles, and the like are sometimes 
pushed up the nose by children, and sooner or later 
lead to inflammation and nasal discharge. Foreign 
bodies may enter the nose from vomiting. Insects 
may fly or crawl into the nose. 
In cases in which it is difficult to grasp the 
foreign body with a small blunt hook, scoop, or 
properly curved forceps, or to push it back into 
the pharynx, the following device may be em- 
ployed: A small sized Nelaton catheter, to the 
distal end of which a long silk ligature is at- 
tached, is carefully and slowly passed into the 
nares until it reaches the pharynx; the gagging in- 
duced forces the catheter out of the mouth; it is 
then seized and the ligature pulled through, about 
8 inches being allowed to remain outside of the nose. 
A small wad of absorbent cotton fastened to the 
buccal end is slowly drawn upward into the pos- 
terior nares and along the inferior meatus. The 
foreign body, particularly if it is a tack or an 
object with jagged edges, is generally caught and 
dragged out of the anterior nares with the cotton. 
The appearance of the nasal mucous membrane 
after the removal of the offending body is appa- 
rently one of severe ulceration. Under simple 
instillation of lukewarm salt-water (0.75 per- 
cent), or weak boric acid solution, the parts 
readily and quickly assume their normal appear- 
ance. 
NOSE, FRACTURE.-The nasal bones often suf- 
fer from direct violence; the fracture may be com- 
pound, either externally or internally, or both, 
or it may be comminuted, and the injury may be 
limited to the bones themselves, or the septum 
may be bent or crushed in, or the other bones that 
surround the nasal cavities may be involved as 
well. Hemorrhage is always profuse; emphysema 
is occasionally present from the escape of air into 
the tissues, and deformity and swelling are 
generally very considerable. 
Treatment.-No pains should be spared to effect 
reduction as early as possible. Manipulation is 
exceedingly painful, so that, if the displacement is 
at all extensive, it is advisable to give an anesthetic. 
The bleeding, which is sure to be profuse, must be 
checked afterward by injecting ice-cold water, or 
by the application of an ice-bag. Elevation from 
within with a steel director, or a pair of dressing- 
forceps, may be tried first, but they are not of 
much service in really bad cases. In some in- 
stances it is necessary to grasp the fragments with 
smooth-bladed forceps, bent so as not to pinch the 
soft tissues near the nostril, and twist them into 
position. Later on a great deal may be done to 
correct any deformity that is left by means of 
pressure. A spring truss may be used, especially 
at night, outside the face, or, as Erichsen suggests, 
india-rubber bags may be introduced into the 
nostril and inflated. Spectacle- or eye-glass 
splints have also been used with success. Suppu- 
ration is not uncommon, but it is rarely serious; 
ozena and necrosis, however, occasionally occur, 
and when the fracture extends on to the face so 
as to involve the nasal process of the superior 
maxilla, stricture of the lacrimal duct generally 
follows. 
NOSE, POLYPS.-Polyps of the nasal passages 
form soft, gelatinous, semitranslucent masses, pale 
pink or yellow in color, projecting from the surface 
of the mucous membrane, and sometimes reaching 
far into the anterior and posterior nares. At first 
they are small and sessile, and-in any advanced 
case numbers in this stage can be seen between 
the larger ones. Those that project toward the 
front may usually be seen at once (or if the patient 
expires forcibly) forming smooth, pedunculated 
masses very soft to the touch, and moving up and 
down with each breath. The deeper ones may 
require a speculum, and those that grow into the 
posterior nares can only be detected by intro- 
ducing the finger round the margin of the soft 
palate. Occasionally, when one has been exposed 
to the air for any time, the surface becomes dry 
and rough, and then it may possibly be mistaken 
for an overgrowth of the mucous membrane over 
the inferior turbinated bone; otherwise it is difficult 
to see how such an error can arise. 
Symptoms.-Chronic catarrh is always present. 
The breathing is obstructed (especially in wet 
weather, when the polyp swells up); the mouth is 
held open; the voice is altered and becomes 
muffled; the sense of smell, and often that of hear- 
ing, is lost; and nearly always there is constant 
frontal headache. In severe cases the shape of 
the nose may become altered by the internal 
pressure; the lacrimal duct obstructed; the septum 
displaced to one side; and the eustachian tube 
occluded. As a rule, there are no bleeding and 
no offensive discharge, both of which symptoms 
are common in the case of malignant growths. 
Treatment.-There are various ways of removing 
polyps. The simplest is to grasp the neck as high 
up as possible with a pair of slightly curved forceps, 
having long serrated blades, and twist it round and 
round until it comes away. If there is a very 
distinct pedicle, the ordinary wire 6craseur may 
be employed, or the galvanocautery, cocain being 
used to allay the pain and prevent sneezing. 
Polyps that lie far back, in or near the posterior 
nares, can only be snared if the forefinger of the 
other hand is carried around the back of the soft 
palate to guide the loop. The bleeding is free, 
but ceases at once upon the application of ice- 
cold water. The chief difficulty is to make the 
removal thorough; and the operator should not be 
satisfied until the passage between the two nares 
is completely freed. Even then many small growths NOSTALGIA 
must be left behind, and these, released from 
the pressure of the larger ones and stimulated by 
the inflammation that follows the operation, are 
almost sure to spring up rapidly. To prevent this, 
tannic acid or sulphate of zinc may be used as snuff, 
or the cavity may be washed out with boric acid 
and alcohol, or with other astringents; but con- 
stant care is needed. In the worst cases it may be 
necessary to perform Rouge's operation. 
After removal, true polyps return rapidly, hence 
it is necessary to have the case under observation; 
the base of each polyp should be cauterized with 
trichloracetic acid or the galvanocautery. Should 
a young polyp be detected, it should be removed at 
once, and its base treated accordingly. The nasal 
passages should be kept cleansed with some simple 
collunarium, such as chlorate of potassium and 
bicarbonate of sodium in water at 95° F., followed 
by a spray of some bland protective, such as 
albolin or vaselin, to the cauterized surfaces and 
mucous membrane. This local treatment should be 
conjoined with such drugs as will improve the 
constitutional condition of the patient, as arsenic, 
syrup of the iodid of iron, or the hypophosphites. 
See Adenoid Vegetations. 
NOSTALGIA (Home-sickness).-An abnormally 
exaggerated longing for home, relatives, or friends. 
It is most frequent among the Swiss mountaineers 
and other persons who have always led an isolated 
life, and have been more or less dependent upon 
a small circle of relatives and friends for companion- 
ship and diversion. Nostalgia represents a com- 
bination of psychic and bodily disturbances, and 
must be defined as a disease, and may become the 
object of medical treatment. It is most trouble- 
some when it occurs in new military recruits, and 
may lead to melancholia and even death. Often 
the only cure is to allow a return home. Nostalgia 
must not be confounded with disappointment or 
moroseness produced by illness, bad temper, or 
discontent with the temporary position abroad. 
Compulsory absence from home has great influence 
in causing nostalgia, and in these cases there is 
more liability to nostalgia than in those in which 
the patients are at liberty to go where they please. 
NOVARGAN.-Silver proteinate. An organic 
silver-albumin compound containing 10 percent 
of silver. As a bactericide, it is claimed to be 
more effective and less irritating than other protein- 
silver compounds. In the form of a 15 percent 
solution it is said to be useful for the treat- 
ment of gonorrhea, especially as an abortive in 
the first stage. 
NOVASPIRIN.-Methylene-citrylsalicylic acid. 
It is decomposed in the intestines into methylene- 
citric acid and salicylic acid after passing through 
the stomach unchanged. Its diaphoretic action 
is slight, and it is said to be devoid of unpleasant 
effects. It is recommended in influenza, neuralgia, 
gouty and rheumatic conditions. Dose, 8 to 15 
grains. 
NOVOCAIN.-A local anesthetic similar to 
cocain. It is recommended as a substitute for 
the latter and is claimed to be far less toxic than 
any of the cocain substitutes. 
NUCLEIN.-Nuclein is that constituent of the 
cell by virtue of which it grows, develops, and 
reproduces itself. It is the chemic basis of the 
nucleus. Nuclein is contained in the cellular 
envelope of the tubercle bacillus, and it is the 
nuclein which takes the stain. It has been ob- 
tained from the thymus and thyroid glands, spleen, 
testicle, white of egg, and from brewers' yeast. 
It is abundant in the polymorphonuclear leuko- 
cyte, and is set free upon the destruction of those 
corpuscles. When glandular activity is at its 
highest, leukocytosis occurs, hence an increased 
amount of nuclein, and concurrently an increase 
in the germicidal property of blood-serum. The 
number of kinds of nuclein is limited only by the 
different varieties of cells. 
While Vaughan and other authors look upon 
nuclein as the essential element that gives the 
blood-serum its specific germicidal properties, 
there are others (probably the majority) who 
maintain that the ductless glands-thyroid, 
thymus, suprarenal and pituitary bodies-all 
secrete certain essential principles, which not only 
are used for the general body nutrition, but also 
aid in protecting the system against attacks by 
pathogenic microorganisms. 
Many look upon nuclein as the prototype which 
gives rise, by decomposition, to alloxin bodies, of 
which uric acid is a member, and it is believed that 
the latter product in great part depends upon the 
amount of nuclein destroyed in the system, and 
that it rises or falls concurrently with the destruc- 
tion of nuclein. 
Chemically, nuclein consists of a complex pro- 
teid base and nucleinic acid, containing from 5 to 
9 percent of phosphorus. The terms "nuclein" 
and "nucleinic acid" are often used interchange- 
ably, as it is generally impossible to obtain nu- 
cleinic acid from the albuminous base. Physiologic- 
ally, nuclein acts by stimulating glandular activity 
with increase in the number of polymorphonuclear 
leukocytes, and therefore an increase in the germi- 
cidal action of blood-serum. By some authors 
nuclein is supposed to be the "natural antitoxin." 
Nuclein has a selective action and is not germi- 
cidal to certain varieties of bacteria. It, however, 
kills the tubercle bacillus. Introduced into the 
system hypodermically, it causes, within 3 to 5 
hours, an increased frequency of the pulse, a rise 
of 1 degree or more in the temperature of the body 
and an increase in the number of multinuclear 
leukocytes (leukocytosis). In 76 cases of tubercu- 
losis in all stages and with no exclusions, Vaughan 
reports recovery in 24 percent. King reports 30 
similar cases with 22 percent recoveries. The 
remedy to be effective must be given hypoder- 
mically, once daily, over long periods (frequently 
months), selecting a slightly alkaline solution. 
Vaughan employed the 1 percent solution in doses 
of 60 to 80 minims, while King used the 5 percent 
solution in doses of 50 minims. 
Nuclein has been successfully used in diphtheria, 
suppurative tonsillitis and other suppurative 
disorders, also in chronic rheumatism and malaria, 
chronic bronchial catarrh and neurasthenia. 
Experience goes to show, however, that in cases 
in which there is rapid destruction of living tissue 
NUCLEIN NUCLEOALBUMIN 
NYCTALOPIA 
and great depression the remedy is of no benefit 
and may do harm. 
NUCLEOALBUMIN.-One of the series of 
nucleins obtainable from cell protoplasm, poorer 
in nucleinic acid than the plastins of the nucleus. 
It appears to be the most constant of the proteids 
obtainable from cell protoplasm, but is not con- 
fined to cells, being the chief constituent of tissue- 
fibrinogen. The chief proteid of milk (caseinogen), 
the so-called mucin of bile, and the mucinoid sub- 
stance in the mucus of urine, are nucleoalbumins. 
Nucleoalbumin is insoluble in acetic acid, precipi- 
table by magnesium sulphate, not reducible by 
prolonged heat in the presence of an acid. It is 
formed by the combination of nuclein and albu- 
min in the process of digestion. It contains 
phosphorus. The presence of nucleoalbumin in 
the urine has been observed in leukemia, icterus, 
diphtheria, and in scarlatina and other varieties 
of nephritis. 
NURSING.-See Infant Feeding, New-born 
Infant. 
NUTMEG.-See Myristica. 
NUTMEG LIVER.-A mottled appearance of 
the liver, the center of the acini being dark, while 
the periphery is lighter in color. The condition is 
seen especially in passive congestion and in fatty 
infiltration. See Liver. 
NUX VOMICA (Poison Nut, Quaker Button, 
Dogbutton).-The dried, ripe seed of Strychnos 
nux-vomica, containing not less than 1.25 percent 
of strychnin. Its properties are due mainly to 
two alkaloids-strychnin and brucin-with the 
properties of which its own properties are identical. 
In small doses it is a bitter tonic, exciting the secre- 
tions and stiumulating the functions of the body. 
In larger doses it exalts the function of the spinal 
cord, causing tetanic spasms of the extensor mus- 
cles. In toxic doses it paralyzes the functions of 
the spinal cord, arrests respiration, and causes 
death by suffocation. It is valuable as a general 
tonic in cardiac failure, in hemiplegia, dyspnea, 
and in certain forms of amblyopia. Strychnin is 
now the acknowledged remedy for inebriety. 
The tincture of nux vomica is excellent in atonic 
dyspepsia and gastric catarrh, especially in drunk- 
ards and in constipation from atony. It is 
valuable in neuralgia, in the condition known as 
torpid liver, and, through its influence on the 
pneumogastric, in many kinds of coughs. Dose, 
1/2 to 1 1/2 grains. 
The alkaloid strychnin is also contained in the 
St. Ignatius' bean, or ignatia in the proportion of 
1 percent, and in the bark of the tropical blind- 
weed, a creeping vine found in the mountains of 
Tonquin and Cochin China. 
Poisoning by strychnin has some points in 
common with tetanus. In the latter affection the 
lower jaw first manifests stiffness, and is affected 
throughout the attack, while in poisoning by 
strychnin the jaw is not affected until late, and 
then only during the paroxysm. The diagnosis 
of strychnin poisoning from hysteria requires 
attention only for a short time. 
Treatment.-Vomiting should be encouraged if 
convulsions have not already set in; in such case 
the stomach-pump may be used. Quiet and 
absolute rest are to be obtained as soon as possible, 
and the patient removed from every irritation, as 
a mere touch may set up a convulsion. Large 
doses of chloral hydrate may be given in doses of 
1/2 dram, repeated in a half-hour. Potassium 
permanganate given in large doses may be anti- 
dotal. Tannic acid forms an insoluble tannate, 
and iodin in dilute solution and soluble iodids are 
antidotes. Butylchloral hydrate is a very active 
antagonist. Potassium bromid is too slow in 
action for practical use. Chloroform or ether may 
be used- to bring about muscular relaxation. 
Hydrastin hydrochlorid, in doses of 1 grain hypo- 
dermically, has been successfully employed, and 
amyl nitrite has been given by inhalation with 
good result. 
Incompatible with nux vomica and strychnin are 
alkalies and their carbonates, bromids, iodids, 
chlorids, and all other alkaloidal precipitants. 
Oils and fats retard the absorption of strychnin 
salts. Physiologically incompatible are aconite, 
alcohol, amyl nitrite, atropin, chloral hydrate, 
chloroform, curarin, digitalis, hydrocyanic acid, 
morphin, nicotin, paraldehyd, physostigmin, po- 
tassium bromid, urethane. 
Preparations.-Extract Nucis Vomicae should 
contain 5 percent of strychnin. Dose, 1/8 to 3/4 
grain up to a maximum in 24 hours of 2 grains. 
Fluidextract Nucis Vomicae should contain 1 per- 
cent of strychnin. Dose, 1/2 to 11/2 minims. 
Tinct. Nucis Vomicae should contain 1/10 percent 
of strychnin. Dose, 5 to 15 minims. Strychnin, 
an alkaloid obtained from nux vomica, ignatia, 
and other plants, crystalline, intensely bitter even 
in 1 to 700,000 solution, of alkaline reaction, 
soluble in 7 of chloroform, 110 of alcohol, 6700 of 
water. It is a constituent of ferri et strychninae 
citras, pil. laxativae comp., and the elixir, glyceri- 
tum and syrupus ferri quininae et. strychninae phos- 
phatum. Dose, 1/100 to 1/30 grain. Strychninae 
Sulphas, crystalline, efflorescent, odorless, of in- 
tensely bitter taste, even in 1 to 700,000 solution, 
neutral reaction, soluble in 50 of water, in 109 of 
alcohol, and in 2 of boiling water, insoluble in 
ether. It contains 75 percent of strychnin. 
Dose, 1/100 to 1/20 grain, but after tolerance is 
attained much larger doses may be safely used. 
Strychninae Nitras, soluble in 90 parts of cold 
water, 3 of boiling water, in 70 of alcohol, and in 
26 of glycerin, insoluble in ether. It contains 84 
percent of strychnin, and is preferred to the 
sulphate for hypodermic use, being less irritant. 
Dose, 1/100 to 1/20 grain, or more after toler- 
ance is attained. The nitrate in doses of gr. 
1/30 to 1/20, hypodermically three or four times 
daily for a week, and less frequently for two weeks 
longer, removes the craving for stimulants, counter- 
acts the vasomotor paralysis to which most of 
the injurious effects of alcohol are due, and is 
probably in other respects a true antagonist to 
the action of that narcotic poison on the human 
organism. 
NYCTALOPIA.-N yctalopia etymologically 
means night-blindness, but the general usage 
making the term mean night-vision is so strongly NYMPH.® 
intrenched that it is useless and confusing to 
reinstate the old significance. The condition in 
which one sees better at night, relatively speaking, 
than by day, is due to some lesion in the macular 
region rendering it blind; at night the pupil dilates 
more than in the daytime, and hence vision with 
the extramacular or peripheral portions of the 
retina is correspondingly better. Nyctalopia is a 
symptom of serious retinal disease, and not a 
disease in itself. All night-prowling animals have 
widely-dilated pupils, and in addition to this 
they have in the retina a special organ called the 
tapetum lucidum, the function of which is to reflect 
to a focus in front of them the relatively few rays 
of light that enter the widely dilated pupil, and 
thus enable them the better to see their way. 
Hence, the luminous appearance of the eyes of 
such animals in the dark. 
NYMPHO.-See Vulva. 
NYMPHOMANIA.-See Mania. 
NYSTAGMUS.-Involuntary oscillation of the 
eyeball due to spasmodic jerking movements of 
the eye, not interfering with the voluntary move- 
ments, but accompanying them. It is the result 
NYSTAGMUS 
of defective coordination. The involuntary move- 
ments may be horizontal or vertical, oblique, or 
rotations about the visual axis. Internal squint 
is a frequent accompaniment, and there may be 
simultaneous shaking of the head. 
The commonest form of nystagmus is that com- 
ing from some deficiency of vision in both eyes, 
beginning in childhood, particularly in amblyopia, 
the result of the destructive changes after oph- 
thalmia neonatorum and in retinitis pigmentosa. 
It also exists in microphthalmos, albinism, and 
some varieties of congenital cataract. Miners 
who constantly strain their eyes in the darkness 
sometimes develop the disease. Nystagmus from 
cerebral disease is only of symptomatic signifi- 
cance. It is especially important in the diagnosis 
of multiple sclerosis. 
Treatment, beyond simple rest and the relief of 
the distressing symptoms, is of little value. It 
must always be remembered that there is a pos- 
sibility of improving the visual acuity and modify- 
ing the disease by correcting lenses. The prog- 
nosis of the nystagmus is never encouraging, even 
under the most favorable circumstances. OAK 
OBESITY 
o 
OAK.-See Quercus. 
OBESITY.-Obesity may be defined as an 
excessive development of fat throughout the 
body. There are two forms, the anemic and the 
plethoric. 
Etiology.-Heredity is a potent factor. Over- 
indulgence in carbohydrates, fats, and albumins 
is a frequent cause. Diseases marked by defec- 
tive oxidation, as chlorosis and sexual continence, 
are often the exciting conditions of this disease; 
so, too, is lack of exercise or muscular inactivity. 
Morbid Anatomy.-Increased subcutaneous fat, 
rounded face, pendulous cheeks, protuberant 
abdomen, and gross legs and buttocks are evident. 
There is an accumulation of fat over the chest and 
in the mediastinum, and enlarged liver and in- 
creased intraabdominal fat. In the later stages 
there is a fatty infiltration of the heart-muscle. 
Pathology.-Although corpulent individuals 
may eat but little fatty foods, they are frequently 
hearty eaters of all classes of foods. The carbo- 
hydrates are not only directly productive of fat- 
increase, but by saving the stored fat, indirectly 
aid in the development of this condition; hence 
sugars, starches, and alcohol (beer in particular) 
are productive of corpulence. Alcohol, by has- 
tening the metabolism of albumin, sets free fat- 
producing substances which may be stored. 
Diminished oxidation from anemia, for example, 
or lack of muscular exercise, favors this condition. 
Symptoms.-The increased bulk of the patient 
renders his movements sluggish and may interfere 
with locomotion, producing a waddling gait. 
Dyspnea, from mechanic interference with respi- 
ration, fatty chest-wall, mediastinal fat, or enlarged 
liver, are early symptoms. Later, a true cardiac 
dyspnea from fatty infiltration of the heart- 
muscle, secondary to arteriosclerosis, may arise. 
A late symptom is the effusion which takes place, 
showing itself as anasarca, ascites, hydroperi- 
cardium, and hydrothorax. Eczema, secondary 
to intertrigo, adds much to the discomfort of the 
patient. 
Prognosis.-Marked corpulence is not incom- 
patible with long life and considerable comfort. 
When excessive, the conditions mentioned are 
likely to supervene, and death, often sudden, re- 
sults. The prospect of recovery is lessened by 
the fact that most patients find the treatment 
irksome, and are induced with great difficulty to 
continue it. 
Complications.-The obese are especially prone 
to contract heart disease, diabetes, asthma, gall- 
stones, apoplexy, gout, disturbances of secretory 
organs. They stand major operations poorly and 
can make little resistance when attacked by 
severe acute infections. 
Treatment.-Two indications present them- 
selves: (1) Diminish the food-supply, and (2) 
oxidize the fat already stored. For the first, 
3 prominent systems are those of Banting, Ebstein, 
and Oertel. 
The Banting system nearly excludes fats, forbids 
the largest possible amount of sugar and starches, 
and limits the daily amount of fluids taken to 
35 ounces. The patients are practically starved, 
in that they are allowed only 20 to 25 ounces of 
dry food daily, about one-half of this being meat. 
The fault of this method lies in its failure to secure 
elimination of waste products, and it is likely to 
result in serious malnutrition. 
The Ebstein method allows fat on the theory 
that it does not produce stored fat and clogs the 
appetite. Sugar- and starch-containing vege- 
tables, as potatoes and all farinaceous foods- 
3 1/2 ounces of bread each day being excepted- 
are forbidden. The quantity of fluids is limited. 
Black tea, without milk or sugar, and fight wines 
are allowed. A moderate amount of meat is 
permitted. 
The Oertel system not only regulates the diet, 
but pays especial attention to the heart and circu- 
lation. For convenience, these patients are 
divided into 2 classes: (1) Those in whom there 
are no marked respiratory and circulatory dis- 
turbances, and (2) those in w'hom the oxygen 
intake is diminished, so that dyspnea is readily 
excited. For the first class double the amount 
of fat and carbohydrates, with a much larger 
amount of albuminates, is allowed, as compared 
with the second class. In the latter class the 
amount of liquid ingested is markedly reduced. 
As compared with the Ebstein and Banting sys- 
tems, it gives nearly the same amount of albumin- 
ates as the Banting, and one-half to three-quarters 
more than the Ebstein. It allows from 3 to 4 
times as much fat as the Banting, and from one- 
third to one-half as much as the Ebstein. For 
the carbohydrates, the same to one-third more 
than the Banting, and one-half more to double 
that of Ebstein. When exercise can be taken, the 
more generous diet of Oertel should be chosen. 
Other systems have been employed, and may be 
adapted to individual patients, but that of Oertel 
has a wider application than any other, especially 
when combined with systematic exercise to 
strengthen the heart-muscle and massage to 
stimulate the circulation. In detail, the diet 
should consist chiefly of albuminates-lean of 
roast or boiled beef, veal, mutton, game, and eggs. 
Green vegetables, as cabbage and spinach, are 
allowed;fat and carbohydrates only in small quan- 
tities, and 4 to 6 ounces of bread a day. The 
liquid drunk must be limited to 6 ounces of coffee, 
tea, or milk, morning and evening, with 12 
ounces of wine, and 8 to 16 ounces of water 
during the 24 hours. In warm weather this 
amount may be slightly increased, but beer is OCCUPATION NEUROSES 
OINTMENTS 
absolutely prohibited. To prevent formation of 
fat, the following diet table should be observed: 
Morning.-One cup of coffee or tea, with a little 
milk, altogether about 6 ounces. Bread, 3 ounces. 
Noon.-Three to 4 ounces of soup; 7 to 8 ounces 
of roast or boiled beef, veal, game, or not too fat 
poultry; salad or a light vegetable; a little fish 
(cooked without fat); 1 ounce of bread or farina- 
ceous pudding (never more than 3 ounces), and 
3 to 6 ounces of fresh fruit. In hot weather, or in 
absence of fresh fruits, 6 to 8 ounces of light wine 
may be taken. 
Afternoon.-Coffee or tea with milk to 6 ounces, 
with at most 6 ounces of water; exceptionally, 
1 ounce of bread. 
Evening.-One or 2 soft-boiled eggs, 1 ounce of 
bread, perhaps a small quantity of cheese; salad and 
fruit; 6 to 8 ounces of wine with 4 or 5 ounces of 
water. Thus far the indication has been to furnish 
less food for the patient to oxidize, and at the 
same time sufficient for purposes of nutrition. 
The second indication is to increase the oxidation 
of fat in the body. This is accomplished by 
massage, exercise in the gymnasium, or, preferably, 
in the open air. The latter comprises walking, 
mountain-climbing, cycling, and, what is of great 
value when possible, horseback exercise. Turkish 
baths are useful to remove surplus fluids from 
the body, but should be employed with great 
hesitation if any circulatory disturbances are 
present. Of health resorts Carlsbad and Marien- 
bad are most frequently chosen. Here the re- 
stricted diet, systematic exercise, and purgative 
waters combine to give relief. The regimen must 
be continued after the return of the patient to his 
home, else the betterment will not be permanent. 
Of the drugs in popular use most are inefficient 
and many are harmful. It is not likely that 
any one drug will meet the various conditions 
arising from the complex processes which result 
in fat production and fat storage. Should these 
be mentioned individually, it would be merely 
to give their contraindications. The one which 
has given the best results is thyroid extract, and 
this must be administered with the precautions 
enumerated under Thyroid Treatment (5. v.). 
OCCUPATION NEUROSES.-A group of affec- 
tions of the nervous system, characterized by the 
occurrence of spasm (cramp) and pain in groups 
of muscles in consequence of overuse or frequently 
repeated muscular acts. It has been noticed that 
many persons suffering from occupation neuroses 
have a family history of nervous affections. 
Varieties.-Writers' cramp; piano-players' cramp; 
telegraphers' cramp; violin-players' cramp;dancers' 
cramp, etc. 
The symptoms of any of the varieties named 
generally develop gradually and slowly, by a 
feeling of stiffness in the used member; the part 
feels fatigued and heavy, until it is impossible to 
use it, from the occurrence of spasmodic contrac- 
tions; there is pain on using the affected muscles, 
often associated with tremor, and in many cases 
with an actual paralysis. Associated with the 
loss of power to follow the usual occupation are 
nervousness, mental worry, and often depression. 
There is often the sensation of prickling and 
numbness in the crippled member. The electro- 
contractility is preserved until the atrophy of 
nonuse develops. 
Prognosis is often unfavorable, although some 
recoveries are reported. 
Treatment consists of rest to the part and mental 
quiet, with tonics and other means to improve the 
general nutrition. Faradism in weak applications 
once or twice weekly seems useful. The following 
combination may be of value (Hughes): 
I|. Zinc phosphid, gr. ij 
Extract of nux vomica, gr. x 
Iron albuminate, gr. xxx. 
Make 30 pills. One after meals. 
OCULOMOTOR PARALYSIS.-See Eye-muscles 
(Paralysis). 
OINTMENTS (Unguenta).-Soft, fatty mixtures 
of medicinal agents with a basis of lard, petro- 
latum, or fixed oils, with a solid fat, such as wax 
or spermaceti They are intended for application 
to the skin by inunction, and have a melting-point 
which is below the ordinary temperature of the 
human body. The official unguentum is pre- 
pared by fusing together 80 parts of benzoinated 
lard and 20 parts of white wax, and is the basis of 
2 other ointments, while 9 have benzoinated 
lard, and 3 have lard as their basis. There are 
24 official ointments. 
Title. 
Percent of Ac- 
tive Constituent. 
Base. 
U nguentum ... 
Unguentum: 
Acidi borici 
Acidi tannici.. . . 
Aquae rosae 
White wax, 20; ben- 
zoinated lard, 80. 
Boric acid, 10 
Glycerin and oint- 
ment. 
Stronger rose water, 
19. 
Paraffin, 10; white 
petrolatum, 80. 
Tannic acid 20. 
Spermaceti, 12.5; 
white wax, 12; al- 
mond oil, 56; borax, 
5. 
Diluted alcohol, 5; 
wool-fat, 20; Ben- 
zoinated lard, 65. 
Benzoinated lard, 94. 
Olive oil, 49; oil of 
lavender flowers, 1. 
Ointment, 80. 
Prepared suet, 23; 
benzoinated lard, 25 
White petrolatum, 
50; hydrous wool- 
fat, 40. 
Petrolatum, 33. 
Lard. 
Water, 10; hydrous 
wool-fat, 40; petro- 
latum, 40. 
Water, 10; hydrous 
wool-fat, 40; petro- 
latum, 40. 
Benzoinated lard, 80: 
glycerin, 12. 
Lard, 90. 
White petrolatum, 
97. 
Belladonnae 
Chrysarobini.... 
Diachylon 
Gallae 
Hydrargyri 
Hydrargyri am- 
moniati. 
Hydrargyri dilu- 
tum. 
Hydrargyri ni- 
tratis. 
Hydrargyri oxidi 
flavi. 
Hydrargyri oxidi 
rubri. 
lodi 
lodoformi 
Phenolis 
Extract belladonna 
leaves, 10. 
Chrysarobin, 6 
Lead plaster, 50 . .. 
Nutgall, 20 
Mercury, 50; oleate 
of mercury, 2. 
Ammoniated mer- 
cury, 10. 
Mercurial ointment, 
67. 
Nitrate of mercury, 
abt., 12.5. 
Yellow oxid of mer- 
cury, 10. 
Red oxid of mer- 
cury, 10. 
lodin, 4; potassium 
iodid, 4. 
Iodoform, 10 
Phenol, 3 OLD AGE 
OLD AGE 
shares in the general change, the heart-beat be- 
coming weakened and often intermittent, the rate 
not being materially altered. The activity of the 
involuntary muscles diminishes. The powers of 
digestion become lessened, inducing constipation. 
The accommodation of the eyes fails; and the 
expulsive force of the bladder diminishes. The 
skin becomes wrinkled. There is shrinkage of 
the elastic tissues, and adipose tissue is absorbed 
and the cutis' thinned; the hair-roots undergo 
atrophy, and the color of the hair is lost. The 
lungs, spleen, lymphatic glands, uterus, and 
ovaries become more or less atrophied, and the 
functional powers of testes diminish or cease. The 
brain and spinal cord shrink in size, reflex action 
becomes sluggish, and mental concentration and 
energy lessen. 
Other morbid changes peculiar to old age are 
thickening of the walls of the arteries, atheroma, 
and calcification thereof. Thrombosis and em- 
bolism are not infrequent results, and cerebral 
hemorrhage is an imminent danger. The heart- 
valves are often atheromatous or calcified. Costal 
cartilages may calcify ancj impede respiratory 
movement. "Arcus senilis," a ring of degenera- 
tion, is often seen near the margin of the cornea, 
and cataract is common. The atrophy of mind 
may become actual dementia, and the lungs 
become emphysematous. Deafness and paralysis 
agitans are common, and joint-affections appear. 
Cirrhosis of the liver is seldom delayed to old age, 
while granular degeneration of the liver com- 
mences in old age. The prostate is liable to fibroid 
enlargement, causing retention of urine and the 
train of results dependent upon it. 
Catarrhs of the air-passages are very prone to 
persist and extend, and to set up a form of lobu- 
lar pneumonia. Wounds are liable to slough, but 
heal most readily. Fatality ensues in old age 
often from gradual enfeeblement of the powers 
without predominant lesion of any organ. Cere- 
bral hemorrhage and cardiac failure are frequent 
modes of death, but pneumonia gives greatest 
mortality. 
Moderate and continous activity of mind and 
body, moderate and regular hours of sleep, a spare 
diet, little or no indulgence in alcoholic liquors, 
and particularly a guarded use of flesh food, are 
the most salient points conducing to length of life. 
The very aged have seldom been addicted to the 
use of drugs. A robust frame, a bodily and mental 
stature above the average, the power of sound 
sleep, of speedy recovery after fatigue, good re- 
productive power, and long retention of the hair of 
the scalp are criteria of capacity for prolonged life. 
Serious illness lessens the prospect. The very 
aged are seldom found to be the offspring of imma- 
ture marriages, or to have contracted such them- 
selves. Elder children appear to have an advan- 
tage over the younger. 
In the treatment of illnesses of the aged, the fail- 
ing powers of digestion, of repair, and of vasomo- 
tor accommodation fnust be kept constantly in 
mind. The dietary should contain less meat and 
more milk and farinaceous foods than that of the 
young or middle-aged. Fatty matters are less 
Title. 
Percent, of Ac- 
tive Constituent. 
Base. 
Unguentum: 
Picis liquid®. ... 
Tar, 50 
Lard, 35; yellow wax, 
15. 
Potassii iodidi... 
Potassium iodid, 10; 
potassium carbo- 
nate, 0.6. 
Benzoinated lard, 80; 
water, 10. 
Stramonii 
Extract of stramon- 
ium, 10. 
Hydrous wool-fat, 
20; benzoinated 
lard, 65; diluted 
alcohol, 5. 
Sulphuris 
Washed sulphur, 15. 
Benzoinated lard, 85. 
Veratria® 
Veratrin, 4 
Benzoinated lard, 90; 
almond oil, 6. 
Zinci oxidi 
Zinc oxid, 20 
Benzoinated lard, 80. 
Zinci steratis.. . . 
Zinc stearate, 50.. . 
White petrolatum, 50. 
The process of compounding an ointment or a 
cerate is sufficiently simple, being generally a mere 
matter of triturating the ingredients together in a 
mortar, or of their incorporation on a slab by means 
of a spatula. When extracts, powders, or gritty 
substances are ordered, the ingredients should 
first be pulverized into a fine powder, then tritu- 
rated with a small quantity of the basis into a 
smooth, impalpable paste, the remainder of the 
basis being added gradually, until the whole is thor- 
oughly incorporated. A warm mortar may be 
required for hard extracts. Soluble salts should 
be triturated with a little water before adding the 
excipient. Camphor needs a little alcohol to 
enable it to be pulverized, and iodin should be 
rubbed to a fine powder, a little alcohol then added, 
and finally the excipient by degrees. Sulphur 
iodid requires persevering work with a small 
portion of olive oil. Borax should be triturated 
with glycerin, and red mercuric oxid with distilled 
water. A bone or horn spatula should be used 
for all ointments, as steel or iron blades will injure 
many substances, particularly alkaloids, free 
acids, tannin or iodin, and several of the mercurial 
salts. Volatile substances should be added last, 
and quickly worked in, so that their evaporation 
may be as slight as possible. 
OLD AGE.-The period of life in which the 
degenerative changes that set in after middle life 
become apparent. It does not correspond to any 
definite term of years, but is hastened by want, 
confinement, hardship, and mental anxiety, by 
exposure to mercurial and nitrous fumes, and 
the habitual use of alcohol and poisonous drugs. 
Some persons are old at 40, and some hardly so at 
70. The normal anatomic and physiologic changes 
are well seen in the bones, which become more 
brittle and lighter, but without reduction in size, 
and hence fractures more readily produced, especi- 
ally in the spongy portions of the bones, in the 
neck and trochanteric region of the femur. The 
cartilaginous portions of the body are thinned, 
slightly lessening the height. The alveolar 
processes of the jaw are absorbed, the teeth loosen- 
ing and falling out, and the angle of the jaw is 
enlarged. The face is shortened and the chin 
protrudes. Voluntary muscles waste with ensuing 
loss of power and increasing difficulty in main- 
taining an erect carriage. The cardiac muscle OLEATES 
OMENTUM 
easily tolerated. Malted and predigested aliments 
may supplement the diet as age advances. 
Changes of temperature must be guarded against, 
and the liability to bronchitis should dictate cau- 
tion in exposure to cold or damp air. 
OLEATES.-Liquid solutions of metallic salts or 
alkaloids in oleic acid, intended for external admin- 
istration. They are not definite chemical com- 
pounds, though the term is also employed in trade 
to designate certain solid preparations which are 
claimed to be chemical compounds of the same 
acid with various bases. There are 5 official 
oleates, three of which have olive oil, as well as 
oleic acid. 
mon with olive oil. By exposure to the air, olive oil 
soon becomes rancid. Olive oil enters into the 
composition of several cerates, ointments, and 
plasters, notably emplastrum plumbi and unguen- 
tum diachylon. Olive oil is emollient and 
protectant. 
Carbolized oil, consisting of a 5 to 10 percent 
solution of carbolic acid in sweet oil, was at one 
time extensively used in the treatment of wounds. 
Since it has been shown that the amount of acid 
employed is ineffective, so far as any antiseptic 
properties are concerned, the practice has been 
abandoned. Sweet oil was in extensive use as a 
wound dressing, especially after amputation, by 
the older surgeons. It had the advantage of 
being bland and unirritating and not allowing the 
dressing to adhere to the cut surfaces. Olive oil 
forms one of the substances in repute for the prep- 
aration of instruments used in the surgery of the 
mucous cavities. In the treatment of unusually 
tight strictures of the urethra, the injection of a 
little sweet oil with a syringe will often prove more 
serviceable than anointing the instrument. As 
an emollient, sweet oil is largely employed in en- 
emata. It has a special tendency to soften scybala 
and assist in their removal. It also serves to re- 
duce the irritation which accompanies the presence 
of seat-worms. It is also used in large and fre- 
quently repeated doses in cases of biliary colic. 
Olive oil enters into the composition of a number 
of preparations employed in the local treatment 
of skin-diseases. Employed alone, it is useful to 
soften crusts and scales and to remove epithelial 
debris as a preliminary to more active treatment. 
OMENTOPEXY.-See Liver, Cirrhosis. 
OMENTUM.-The omentum forms an extremely 
mobile covering to the intestines, and it may glide 
into any part of the abdominal cavity, or commu- 
nicating pouch, or hernial sac, and readily pro- 
lapses into a wound. Its displacement may be 
caused by the peristaltic movements of the intes- 
tines, by movements of the chest, or of the abdom- 
inal wall, or be due to gravity. At any point the 
omentum may become adherent, which in some 
cases may have a beneficial result: (1) by closing a 
threatened or actual intestinal perforation; (2) by 
encysting an infectious mass such as a diseased 
appendix; (3) by confining a septic peritonitis to a 
limited region of the abdomen. Advantage is 
taken of the omentum for grafting over a weak line 
of suture, and for establishing a venous anastomosis. 
On the other hand harm arises from omental adhe- 
sions; a band may be formed under which a coil 
of intestine slips and becomes strangulated, whether 
in the abdominal cavity, or in a hernial pouch; 
one end of the omentum being fixed, the peristaltic 
movement of the intestine may induce torsion of 
the omentum, and so gangrene; omental adhesions 
may furnish additional blood supply to a uterine 
fibroma and encourage the rapid growth of the 
tumor. 
A tumor of the omentum is movable and not 
covered by intestine. It may consist of rolled up 
or matted omentum, the result of inflammation, or 
it may be a cyst or of a vascular, fibrous, or sarco- 
matous nature. Treatment.-An exploratory in- 
Title. 
Composition 
Oleatcm: 
Atropinae.... 
A tropin, 2 grams; oleic acid, 50 grams; olive 
oil to 100 grams. 
Cocainae 
Cocam, 5 grams; oleic acid, 50 grams; olive 
oil to 100 grams. 
Hydrargyri. . 
Yellow mercuric oxid, 25 grams; oleic acid to 
100 grams. 
Quininae 
Quinin, 25 grams; oleic acid, 75 grams. 
Veratrinae. .. 
Veratrin, 2 grams; oleic acid, 50 grams; olive 
oil to 100 grams. 
OLEORESINS (Oleoresinae).-Liquid prepara- 
tions consisting principally of natural oils and 
resins extracted from vegetable substances by 
percolation with acetone. They differ from fluid- 
extracts in not bearing any uniform relation of c.c. 
to the gram of drug, in containing principles 
which though soluble in acetone are not so in 
alcohol, and in some instances being devoid of 
principles which are insoluble in acetone but solu- 
ble in alcohol. They are the most concentrated 
liquid preparations of drugs which can be pro- 
duced. The official oleoresins are 6 in number. 
Title. 
Average Yield and 
Properties. 
Dose. 
Oleoresina: 
Aspidii 
10 to 15 percent. Tseniacide. 
30 grains. 
Capsici 
5 percent. Stimulant, rube- 
1/2 grain. 
Cubeb® 
facient. 
18 to 25 percent. Diuretic, 
7 1/2 grains. 
Lupulini 
expectorant. 
50 percent. Tonic sedative. 
3 grains. 
Piperis 
5 percent. Stimulant 
1/2 grain. 
1/2 grain. 
Zingiberis ... 
6 to 8 percent. Stimulant. . 
OLFACTORY DISEASE.-See Anosmia. 
OLIGOCHROMEMIA AND OLIGOCYTHEMIA. 
-Deficiency in hemoglobin and red cells re- 
spectively. See Blood. 
OLIGOHYDRAMNIOS.-See Amnii, Liquor. 
OLIVE OIL (Sweet Oil, Salad Oil).-"A fixed 
oil expressed from the ripe fruit of Olea europoea" 
(U. S. P.). Cotton-seed oil, poppy oil, colza oil, 
ground-nut oil, and lard oil are used in immense 
quantities as substitutions for olive oil, since, with 
the exception of the common adulterant, cotton- 
seed oil, which is slightly irritating, all these 
varieties of oil have many of the properties in com- OMPHALORRHAGIA 
OPHTHALMOMETER 
cision should be made, and if the tumor is found 
movable the whole of the omentum should, as a 
rule, be excised up to the transverse colon (Spencer 
and Gask). 
OMPHALORRHAGIA.-See Umbilical Cord. 
ONOMATOMANIA.-Functional derangement of 
speech, of which 5 varieties are described: (1) A 
powerful effort to recall some word; (2) an irresist- 
ible impulse continually to repeat a word, by 
which the patient seems perplexed; (3) the patient 
attaches some peculiar and dreadful meaning to a 
commonplace word; (4) the patient attaches talis- 
manic significance to certain 
words, which he repeats as 
a safe guard; (5) the patient 
is impelled to spit out some 
word, like a disgusting mor- 
sel. A word is a complexus 
of images, localized in certain 
centers of the cerebral cortex, 
the images being partly audi- 
tive, partly visual, partly 
motor. " Onomatomania is 
characterized by irregular ac- 
tion of one or several ver- 
bal images, resulting from 
some functional disturbance 
of the corresponding center." 
In simple onomatomania the 
patient is possessed with the 
idea of recovering a word 
that escapes him. The word 
is familiar; its significance 
can be given; the place where 
read or the time when heard 
can be given, but the word 
cannot be recalled. Articu- 
late speech may be at fault. 
The patient knows the word, 
sees it written before him 
but cannot articulate it. He 
may utter a synonym or a 
similar word. In associated 
onomatomania words acquire 
a peculiar or preponderant 
meaning. See Aphasia, 
Speech Defects, etc. 
ONYCHIA.-See Nails 
(Diseases). 
OPEN-AIR TREATMENT. 
-In conjunction with vaccine therapy open air 
is advocated in empyema. It is efficacious in 
burns, lobar pneumonia, bronchopneumonia, in- 
operable cancer, pulmonary and surgical tubercu- 
losis. It is used conjointly with X-rays to pre- 
vent recurrence after operation for carcinoma of 
the breast. See Burns, Tuberculosis, etc. 
OPERATIONS IN GENERAL.-See Abdominal 
Section. 
OPHTHALMIA NEONATORUM.-See Con- 
junctivitis (Purulent). 
OPHTHALMIA, SYMPATHETIC.-See Sympa- 
thetic Ophthalmia. 
OPHTHALMIC REACTION OF TUBERCULO- 
SIS.-See Tuberculin. 
OPHTHALMOMETER.-An instrument used for 
the determination of the kind and amount of corneal 
astigmatism. It is less exact than the retinoscope, 
and, moreover, it is very expensive. That of Javal 
and Schiotz consists qf a telescope attached to a 
graduated arc, upon which are two objects called 
mires, the left one being fixed, while the right is 
movable. These mires are of white enamel, one 
quadrilateral in shape and the other the same size, 
except that on one side it is cut out into 5 steps. 
The observer looks through the tube, which con- 
tains a combination of convex lenses and a bi-re- 
fracting prism, and sees 4 magnified images in a 
A. The perimeter-bar. B, B. Telescope. C. Chin-rest. D. Disc of radiating lines 
and concentric circles. E. Eyepiece at which the observer sits. H Head-rest. L. 
Lights, M, M. The mires, or targets. P. Pointer, indicating the axis by the degree 
numbers on the peripheral border of the disc. 
The Ophthalmometer of Javal and Schiotz. 
line on the cornea under examination. He first 
finds the meridian of least refraction by moving the 
semicircular arm to the position in which the 2 cen- 
tral images are furthest apart. The mires are then 
moved together until the 2 central images on the ob- 
served cornea touch and their central black lines co- 
incide-the lowest step of one image with the side 
of the other. The arm is now turned at right angles 
to this meridian, and the overlapping of the 2 centra 
images is noticed; for each step overlapping there is 
a difference of 1 diopter between the meridians. 
In higher degrees of astigmatism we add 5 diop- 
ters to the number of steps protruded on the 
other side. At 5 diopters of astigmatism the steps 
exactly cover the plain quadrangular mire. 
The meridian of least curvature corresponds to OPHTHALMOPLEGIA 
OPHTHALMOSCOPY 
the axis of astigmatism. The findings of the 
ophthalmometer are not exact. No account is 
taken of the lenticular astigmatism, and even 
though the cornea is at fault, no rules for adapting 
the ophthalmometric results can be formulated. 
Speaking broadly, the total astigmatism is approxi- 
mately equal to the amount indicated by the oph- 
thalmometer, expressed as myopic astigmatism, 
combined with an inverse myopic astigmatism of 
0.75 D;. or, in other words, when there is no cor- 
neal astigmatism by the opthalmometer, the test- 
lens will likely show about 0.75 D of inverse astig- 
matism (Bull). 
large surface of the eye. In the direct method a 
very small mirror is as good or better than a large 
one. A small sight-hole gives a more distinct 
image, and does not necessitate so much accomo- 
dation or optic aid in examining slightly ametropic 
eyes. The large sight-hole is better for the accu- 
rate estimation of refraction. As the direct 
method is more generally employed, and refraction 
is not ordinarily estimated by ophthalm oscopy, and 
retinoscopy is usually performed with a special plane 
retinoscopic mirror, for all practical purposes it is 
better to use a small mirror with a small sight-hole. 
There are many forms of ophthalmoscopes, for 
all of which some advantage is claimed. The 
model of Loring is cheap, and answers all practi- 
cal purposes, but it is awkward to use, and neces- 
states removal from the eye and a combination of 
lenses to secure the higher powers. More expen- 
sive and, at the same time, more convenient are the 
models of Morton, Harlan, Gould, Pyle, and others. 
Use of the Ophthalmoscope.-The ophthalmo- 
scope may be used in 2 ways-by the direct and 
indirect methods. 
Direct Method.-The patient is placed in front 
of the source of illumination, and to the side of the 
eye to be examined, the light behind him so that 
it shines on his temple, just touching the tips of 
the outer lashes. He is then told to look straight 
ahead to an object on a level with his eyes across 
the room. To examine the patient's right eye, 
the surgeon sits or stands, and holds his ophthal- 
moscope in his right hand before his own right eye. 
Mires Exactly Approxim- 
ated. 
Mires Overlapping One 
Diopter. 
OPHTHALMOPLEGIA.-See Eye Muscles 
(Paralysis). 
OPHTHALMOSCOPY. Theory.-It is self-evi- 
dent that rays reflected from the fundus of the eye 
emerge from the eye in the same direction as that in 
which they enter it, the refractive media of the eye 
having the same action on light whether pass- 
ing in or out. However, as ordinarily seen, 
the pupil is black. There is no light reflected 
from the patient's eye into ours, because our own 
eyes are not a source of light. Now, if the 
observer's eye is artificially made the source of 
light, and if he looks in the same direction as that 
in which the luminous rays enter the observed 
eye-as, for instance, through the sight-hole of a 
mirror-illumination renders the interior of the 
eye visible. This is the fundamental principle of 
the ophthalmoscope, and it was first explained 
and made practical by Helmholtz in 1851. 
Description.-The simplest form of ophthalmo- 
scope is a mirror with a hole in the center, which 
is held close to the patient's eye in such a manner 
as to reflect light from a luminous point near by 
into it, illuminating the interior of the eye, and 
revealing the details of the fundus. The ophthal- 
moscopes in use to-day are of more intricate 
mechanism, and render the examination much 
easier and more satisfactory. The mirror most 
used in this country is small, concave, oblong or 
round in shape, with a central aperture of from 2 
to 4 mm. in diameter, and so arranged that it can 
be tilted or rotated from side to side, thus saving 
the trouble of inclining the whole instrument to 
reflect the light properly. By means of various 
ingenious appliances, a series of lenses are incor- 
porated with the instrument in such a manner 
that, by turning a wheel with the finger, the con- 
vex or concave lens of the strength desired can be 
brought before the sight-hole in the mirror. By 
arranging the lenses so that they can be combined, 
the range may be extended from a fraction of a 
diopter to a lens of as high power as is ever required. 
The large mirrors are more useful in the indirect 
method, in retinoscopy, and for illuminating a 
Morton's Ophthalmoscope. 
To examine the patient's left eye, he places him- 
self to the left of the patient and holds the ophthal- 
moscope in his left hand before his own left eye. 
The ophthalmoscope is brought close to the eye 
under examination, the mirror of the ophthalmo- 
scope having been inclined, and the instrument 
held in such position that the light from the 
source of illumination will be reflected directly 
into the patient's pupil; then, if the media are 
clear, a red glare, called the fundus reflex, is seen 
through the hole in the mirror. If the examiner 
wears glasses, he need not remove them; in fact, OPHTHALMOSCOPY 
OPHTHALMOSCOPY 
if he is astigmatic, he had better accustom him- 
self to working with his correcting lenses on. 
Examination of the Media.-The reaction and 
form of the pupil are noticed. If a foreign body or 
opacity is present in the pupillary area, it appears 
as a dark spot on a red background. A slight 
corneal opacity appears only as a mere shadow. 
It must be remembered that spots on the cornea 
and lens always maintain their same relative posi- 
tion and are immovable, while opacities in the vit- 
reous are usually freely movable, and can be diag- 
nosed by their change of position as the patient 
turns the eye quickly in various directions and then 
looks straight forward. To locate corneal or len- 
ticular opacities, in addition to focal illumination 
advantage is taken of the phenomenon of parallac- 
tic displacement, which is governed by the rule 
that opacities lying in front of the pupil move in 
the same direction as the patient's eye, while opac- 
shilling, while to the naked eye it measures only 
1.5 mm. Emerging from the disc is seen the cen- 
tral retinal artery and vein, dividing into inferior 
and superior branches. The veins may readily be 
distinguished from the arteries by their darker 
color and their size-about one-fourth larger. 
Pulsation of the veins is observed under normal 
circumstances, while pulsation of the arteries indi- 
cates a pathologic condition-either rise of intra- 
ocular tension or decrease of blood-pressure. 
Reflexes consisting of bright lines in the middle of 
the blood-vessels are seen. Frequently a depres- 
sion may be seen in the disc called the physiologic 
cupping, caused by the branching of the internal 
fibers of the optic nerve at a lower level than the 
more external ones. This is white, with a sur- 
rounding zone of pink. Pathologic cupping 
includes the whole of the disc, and is characteristic 
of glaucoma. The form, the size, the color, and 
other appearances of the disc must be further 
studied. At the external border of the disc is 
often seen a black, circular pigment ring, bounding 
the opening in the choroid through which the 
optic nerve enters. To the outer side of this is the 
white scleral ring, which is not always distinctly 
circular. A white conus, or even a crescent, may 
be seen at the edge of the disc if there is choroidal 
atrophy. In high myopia this condition is notice- 
able. If there is distinct sign of cupping, the 
extent may be approximately estimated by the 
refractive conditions of 2 points lying at different 
elevations. The difference in diopters in the lenses 
required to distinctly focus the 2 points multiplied 
by 0.35 of a mm. will give the difference in depth. 
It is usual to select one point at the bottom of the 
cup, and the other near the surface. 
The parallax test is based on the fact that in the 
indirect method, while the whole fundus seems to 
move along with the lateral movements of the con- 
vex lens, the floor of the excavation apparently 
moves in the same direction, but at a slower rate. 
This parallax is more marked the deeper the 
excavation. 
The general aspect of the eye-ground is then 
studied, and any abnormalities in the retina, cho- 
roid, or sclera should be noted. If there is absence 
or deficiency of pigment between the retina and 
choroid, the larger choroidal vessels are seen 
through it, and the eye-ground is streaked with 
well-defined interspaces. At any portion of the 
fundus in which both the retina and choroid are 
lacking, the white, glistening sclera is seen shining 
through. To examine the macular region the 
patient is told to look into the light coming from 
the mirror, or, better, beyond it in the same direc- 
tion, which movement of the eye generally brings 
the macula into view. This appears as a dark spot 
isolated in the fundus, with a small, bright spot 
in the center, called the fovea centralis. There are 
usually no vessels to be seen in this vicinity. The 
macular region should always be studied carefully, 
as any lesion or hemorrhage in this location has an 
important bearing on the vision of the patient. 
Refraction by the ophthalmoscope is usually 
accomplished by the direct method. Refraction 
of the macular region is desirable, but as the intense 
Direct Method. 
ities behind the pupil move in the opposite direc- 
tion to the patient's eye, and the extent of this 
apparent movement enables one approximately 
to determine the distance of the opacity either in 
front or behind the pupillary plane. After having 
observed any anomaly of the pupil or media at 
a distance of from 12 to 16 inches, a strong convex 
lens (10 D. to 16 D., according to its location) is 
then wheeled before the sight-hole of the ophthal- 
moscope, which allows the observer to approach 
closer to the patient's eye, and greatly magnifies 
the conditions present. 
Examination of the Fundus.-If the media 
are clear, the surgeon approaches close to the 
patient's eye, and at once the details of the eye- 
ground become visible. The refractive media of 
the eye magnify the details of the fundus about 
14 times, and by this fortunate circumstance the 
minute details of the eye-ground are plainly visible. 
Probably the first distinct object will be a retinal 
vessel which can be easily traced to the most prom- 
inent part of the fundus, the optic disc. At this 
point a bright whitish or pinkish reflex is seen, 
standing out in sharp distinction to the surround- 
ing red fundus. By adjusting the proper lens 
before the sight-hole in the mirror the outlines of 
the disc may be brought sharply into view. The 
average size of the normal disc, as seen by the 
direct method, is nearly that of a 25-cent piece or a OPHTHALMOSCOPY 
OPIUM 
dazzling produced by light makes it almost impos- 
sible, the disc is usually the objective point selected. 
The observer first corrects his own ametropia, 
and as much as possible relaxes his accommoda- 
tion. It is this inability to regulate the relaxa- 
tion of accommodation that makes this test unre- 
liable in simple errors of refraction, and in the 
lower degree of astigmatism it is comparatively 
worthless even in the most skilful hands. The 
retinoscope is a more important and more scientific 
instrument for the objective method of refraction. 
Having relaxed the accommodation and corrected 
his own error, the surgeon moves before the eye 
the lens which gives him the best outlines of the 
disc, and subtracts his own correcting lens from 
the result. In cases of astigmatism the disc is 
usually oval, its long diameter corresponding to 
the axis of astigmatism. Two vessels at right 
angles to each other in the principal meridians are 
refracted separately, and the results noted. 
Glasses should not be prescribed from the ophthal- 
moscopic refraction alone. 
Indirect Method.-The indirect method is less 
valuable than the direct. The image is inverted 
and less magnified (3 or 4 diameters), but one is 
able to see a larger part of the fundus at a glance 
and is not compelled to approach so near the pa 
both in examining the fundus and approximately 
estimating the kind and degree of ametropia, can 
only be obtained after considerable practice. A 
normal fundus in both a light-complexioned and 
dark-complexioned person should be repeatedly 
studied, as abnormal conditions are not recognized 
until one is thoroughly familiar with the normal 
healthy fundus. 
OPISTHOTONOS.-A tetanic condition of the 
muscles, particularly of the back, whereby there 
is an arching backward of the trunk, which may 
rest upon the head and heels. The condition is 
seen in poisoning from strychnin, in tetanus, 
hydrophobia, hysteria, and other tetanic condi- 
tions. In rare instances the muscles in front of the 
spine are affected, when emprosthotonos is the term 
used to describe the condition, the patient's body 
being arched forward. Pleurothotonos is the term 
used when the body is bent to one side or the other. 
OPIUM.-The inspissated juice of the unripe 
capsules of the Papaver somniferum, or poppy, ob- 
tained by incising the capsules and collecting the 
milky juice which is exuded. Most of the opium 
in the American market comes from Smyrna, 
Asia Minor. Opium is a very complex substance, 
and contains, besides morphin and codein, a large 
number of less important alkaloids-narcein, 
narcotin, thebain, laudanin, papaverin, cryptopin, 
and meconin, opianin, paramorphin, and me- 
conic, thebolactic, and sulphuric acids, in ad- 
dition to a variety of extractives. Good opium 
should yield at least 9 percent of morphin. The 
dominant physiologic action of opium is the relief 
of pain. It also causes slowing of the respiration 
and pulse, contraction of the pupils, diaphoresis, 
and constipation; more rarely, nausea and vomit- 
ing, headache, itching of the skin, erythema; 
occasionally, instead of sleep, wakefulness, delirium, 
even convulsions. 
Therapeutics.-The chief indications for the 
use of opium are: (1) To relieve pain from any 
cause except acute inflammation of the brain; 
(2) to produce sleep, particularly in the insomnia 
of low fevers with delirium, in which the combina- 
tion of morphin and chloral is very efficient; 
(3) to allay irritation in the various forms of acute 
nervous erethism; (4) to check excessive secretion, 
as in diarrheas, dysentery, diabetes, ptyalism, 
etc.; (5) to support the system in low fevers and 
other adynamic conditions, when sufficient food 
cannot be retained; (6) as a sudorific, to produce 
sweating in coryza, etc. It is considered of especial 
value in any irritation of the stomach, bladder, or 
bronchi, in severe vomiting, both forms of diabetes, 
gastralgia, colic, and muscular spasm. 
Superficial pain is often alleviated by the plaster 
or by liniments containing laudanum or some 
other fluid preparation. The oleate of morphin 
is said to be very penetrating. 
Intense pain, as from the passage of calculi, is 
best met by the hypodermic injection of morphin 
sulphate in full doses (1/4 to 1/2 of a grain) with 
atropin sulphate (1/100 of a grain). Either the 
solution of morphin or the liquid preparations of 
opium may be given by the mouth in correspond- 
ing doses for the same purpose. 
Indirect Method. 
tient's face. It also enables the surgeon to inten- 
sify his illumination in cases of very small pupil 
or of cloudy media. In this country the indi- 
rect method is being less and less used. The 
method of procedure is usually the same as in the 
direct method, except that the surgeon keeps his 
eye a foot or more away from the patient's face 
and holds in front of the patient's eye a strong 
convex lens. However, the surgeon need use but 
one eye, and may stand directly in front of the 
patient. The lens is usually held at such a dis- 
tance from the eye that the iris just disappears 
from view; a plus spheric 4 D. lens may be held 
before the opening in the mirror to enlarge the 
image and to replace the observer's strain of 
accommodation. By directing the light from the 
mirror through the lens into the eye, an inverted 
aerial image is formed in front of the lens, and it is 
this image that the surgeon sees. In high degrees 
of myopia it is easy to examine the inverted aerial 
image without a convex lens. 
The satisfactory use of the ophthalmoscope, OPIUM 
OPIUM 
Sedative action is obtained by different prepara- 
tions for different organs. The stomach is best 
affected by the solution of morphin in effervescing 
solution. The intestines may be influenced by 
laudanum in a starch enema, or internally by 
Dover's powder, powdered opium, or the pill of 
Apium, especially the latter, with or without 
calomel, as an astringent when the bowel must be 
paralyzed, as in peritonitis, hernia, intussuscep- 
tion, etc. The rectum and other pelvic organs 
are promptly affected by a suppository of the 
extract of opium, 1/4 of a grain, with 1/12 of a 
grain of the extract of belladonna. The ovaries 
and the abdominal and pelvic organs generally 
are markedly susceptible to the analgesic action of 
codein in doses of 1 to 2 grains for an adult in 
severe pain. 
To produce sleep, the most efficient preparations 
are the tinctures, the solution of morphin, pill of 
opium, and Dover's powder, in doses corresponding 
to the degree of insomnia and restlessness present. 
Cough is relieved by the troches, the tinctures, 
and by the solution of morphin in small 
doses with syrup of wild cherry or syrup of 
tolu; also by codein in the last-named syrup. 
Diaphoresis is obtained by the use of Dover's 
powder in either of its forms. 
Children bear opium badly, and for them its 
proportionate dosage should be much smaller than 
for other agents. Morphin should not be given to 
children less than 10 years of age, and never 
hypodermically to those under the age of 15. 
Opium given to a nursing mother will effect the 
child, being partly excreted in the milk. 
Poisoning.-In a child 1 day old 1 minim of 
laudanum has caused death. A medicinal dose 
given to a nursing mother proved fatal to the in- 
fant. A few drops of paregoric have killed a child 
fo 9 months. In the adult 1/6 of a grain of mor- 
phin in one case, and 4 grains of crude opium in 
ahother, have proved fatal. 
A toxic dose produces at first restlessness, in- 
creased mental activity with a feeling of exhilara- 
tion, cardiac stimulation and flushed face. Then 
follows the stage of stupor, when the patient 
feels drowsy, and falls into a deep sleep. The 
pulse is slow and full; respirations are slow and 
labored; pupils are contracted ("pin-point"); 
the skin is warm and dry. During this stage, 
the patient can be aroused, but quickly goes to 
•tleep again. The patient passes insensibly into 
the third stage in which coma is absolute, and 
which is characterized by cyanosis; respirations 
feeble and irregular; muscular relaxation; pulse 
weak and rapid; relaxed, cold, clammy skin; the 
pupils dilate just before death which occurs 
from paralysis of the respiratory center due to 
direct action on the medulla. Postmortem shows 
only congestion of the brain, congested lungs, and 
engorgement of the venous trunks and of the right 
heart. 
The coma produced by opium-narcosis, when 
deep and when a history of the case cannot be 
obtained, is almost impossible of differential diag- 
nosis from that due to alcohol, apoplexy, uremia, 
epilepsy, etc. The odor of breath may point to 
laudanum or some other preparation of opium. 
The pupils are very much contracted in opium 
poisoning. See Coma. 
Treatment.-Potassium permanganate is the 
best antidote to opium or morphin in the stomach, 
given in dose about one-half greater than the 
quantity of morphin present, and repeated in less 
quantity from time to time in cases where the 
poison has been administered hypodermically, so as 
to neutralize the morphin excreted by the gastric 
mucous membrane. If an opium preparation has 
been taken, or the alkaloid morphin itself, vinegar 
should be added to the permanganate solution. 
Atropin antagonizes the cerebral action of 
morphin, also its action on the pupils, respiration, 
heart, and arterial tension; but if given too freely, 
it will endanger the case by substituting bella- 
donna-narcosis for opium-narcosis; 1/120 of a 
grain hypodermically every 15 minutes for 3 doses 
is generally sufficient. It is unsafe to be guided 
in this respect by the pupils. Caffein is also 
physiologically antagonistic, and is generally used 
in the form of strong black coffee, frequently 
administered. 
The chief indications in opium- or morphin- 
poisoning are to antidote any of the poison in the 
stomach and to wash out that viscus repeatedly 
at short intervals; to maintain respiration and 
keep up the circulation; and to prevent sleep by 
noises, flagellation, or electricity. Strychin is an 
efficient antagonist to the respiratory paralysis, 
and may be used in lieu of atropin, or in connec- 
tion therewith. Amyl nitrite should also be used 
when the heart shows signs of failure. Capsicum, 
the tincture, 1/2 to 1 ounce, by injection into the 
rectum, is said to give almost instantaneous results 
in antagonizing the stupor of opium-posioning. 
For further directions, see under Poisoning. 
Preparations.-O Acetum. {black drop), opium- 
strength 10 percent, with nutmeg and sugar in 
dilute acetic acid. Is now 1/3 weaker than form- 
erly, having the same strength and dose as tincture 
of opium. O. Deodoratum {denarcotized opium) 
is powdered opium free from narcotin and the 
odorous principles, which are supposed to cause 
the unpleasant after-effects of the drug. It should 
yield 12 to 12 1/2 percent of morphin, and is a good 
preparation, being a purified opium with a fixed 
morphin standard. The proprietary article named 
Svapnia is a similar preparation. Dose, 1/2 to 
3 grains. O. Emplastrum-contains of extract of 
opium 6 parts, adhesive plaster to 100. O. Ex- 
tractum, an aqueous extract containing 20 percent 
of morphin, and freed from principles insoluble in 
water. Dose, 1/4 to 2 grains. O. Granulatum, 
opium dried and reduced to a coarse powder. 
It should yield from 12 to 12 1/2 percent of mor- 
phin. Dose, 1/2 to 3 grains. O. Pilulae, each pill 
contains about 1 grain of powdered opium in- 
corporated with soap. Dose, 1 to 3 pills. 
O. Pulvis-opium dried at a temperature not ex- 
ceeding 185° F., and reduced to a very fine powder. 
It should contain not less than 12 nor more than 
12 1/2 percent of crystallized morphin, when 
assayed by the official process. Dose, 1/2 to 3 
grains. Pulvis Ipecacuanhae et Opii {Dover's OPIUM HABIT 
OPSONIN THERAPY 
powder)-has of ipecac 10, powdered opium 10, 
sugar of milk 80, rubbed together into a very fine 
powder. Dose, 5 to 15 grains. O. Tinctura, 
laudanum, opium-strength 10 percent, or 48 grains 
to the ounce. Morphin-strength about 6 grains 
(equal to 7 1/2 grains of morphin sulphate) to 
the ounce. Ten minims equal 1 grain of opium 
or 1/8 grain of morphin. Sixty minims equal 
on the average about 120 drops. Dose, 5 to 30 
minims, according to the effect desired. O. Tinctura 
Camphorata, paregoric, has of powdered opium 
4, benzoic acid 4, camphor 4, oil of anise 4, glycerin 
40, diluted alcohol to 1000. Half an ounce con- 
tains nearly 1 grain of powdered opium. It is 
about 1/20 of the strength of laudanum. Dose, 
for an infant 5 to 20 drops; for an adult 1 to 4 drams. 
It is an ingredient of mistura glycyrrhizae composita. 
O. Tinctura Deodorati, an excellent liquid prep- 
aration, being freed from all the noxious and 
useless ingredients soluble in alcohol and ether. 
Opium-strength 10 percent, average morphin- 
strength 6 grains to the ounce. Dose, as of tinc- 
ture of opium. Drops of this preparation nearly 
equal minims. McMunn's elixir is a similar 
preparation, so also is another proprietary nostrum 
named papine. Tinctura Ipecacuanhae et Opii, 
has of tincture of deodorized opium 100 evaporated 
to 80, fluidextract of ipecac 10, diluted alcohol to 
100. Is intended to represent Dover's powder 
in liquid form. Dose, 5 to 15 minims. Trochisci 
Glycyrrhizae et Opii, each troche contains of pow- 
dered opium 1/12 of a grain, with extract of glycyr- 
rhiza, acacia, sugar and oil of anise. Dose, 1 to 
4 troches. O. Vinum {Sydenham's laudanum'), 
opium-strength 10 percent, with the aromatics 
cinnamon and cloves of each 1 percent, in alcohol 
and white wine. A vinous tincture decreased 
somewhat in strength from the wine of 1870. 
Dose, as of tincture of opium. Drops of this 
preparation are larger than those of the tincture. 
See Morphin; Harrison Law. 
OPIUM HABIT.-An irresistible craving for 
opium or its alkaloid, morphin. It is most fre- 
quently acquired as the result of long-continued 
administration of morphin, to relieve some suffer- 
ing caused by a painful or incurable malady, or for 
insomnia. Heredity and a neurotic tendency are 
predisposing factors. Alcoholics often become 
morphin fiends. The chief symptom is the craving 
for the drug. Among other symptoms are irres- 
olution, loss of self-control, moral obliquity, and 
untruthfulness. Epigastric pain or nausea, or 
both, are frequently complained of toward the 
time when another dose is due, though whether this 
is actual or feigned is not always easily determined. 
Mental depression is a more constant and charac- 
teristic symptom, associated with insomnia, intense 
anxiety, restlessness, and a sense of impending 
evil, all relieved for a time by the dose. Diarrhea 
rather than constipation is not infrequent. 
Treatment.-Successful treatment is scarcely 
possible outside an institution, and even within 
one serious difficulties beset the way, chief of which 
is the deception practised by the patient. Patients 
should be divested of their own clothing and put to 
bed in hospital garb, because in this way alone can 
we be sure that morphin is not concealed about the 
person. In the case of women, whenever possible, 
a separate nurse should be assigned to each case. 
The latest testimony favors complete and sudden 
withdrawal of the drug as furnishing a short strug- 
gle, though a severe one. Such treatment is usu- 
ally followed by diarrhea, vomiting, and insomnia. 
Some counsel even that no adjuncts should be 
employed, but certainly there can be no harm in 
the employment of general tonic treatment and 
remedies directed to the irritability of the stomach 
and torpor of the liver. A calomel purge is useful 
at the start. It is a well-established fact that, as 
in alcoholism, the patient should be well nourished, 
given such food as milk, cream, beef-juice, or beef 
peptonoids, rich broths, and beef-teas. When 
there is great asthenia, aromatic spirit of ammo- 
nia, strychnin, and digitalis may be given as 
directed under Alcoholism (q. v.). If possible, an 
occupation of an absorbing kind should be fur- 
nished. In most cases it is impossible to secure the 
consent of the patient to sudden and complete with- 
drawal, when the gradual plan must be adopted. 
The success of either plan depends on securing 
effectual control of the patient, and if this cannot 
be obtained, all efforts fail (Tyson). 
Chloralamid is probably the best hypnotic. It 
is not easy of administration, because of pungent 
taste and difficult solubility. Ten or twenty grains 
are a moderate dose, and are easily soluble in a 
fluidram of a mixture of 2 parts alcohol and 1 part 
glycerin. Of this solution 2 teaspoonfuls should be 
given in a glass of sherry wine or 4 tablespoonfuls 
of milk at the ordinary temperature. Trional and 
sulphonal or somnal may be given in 15- to 20- 
grain doses dissolved in hot water. Hyoscin in 
doses of 1/96 of a grain may also be tried. Chloral 
itself may be used in doses of from 10 to 30 grains. 
If there is cardiac weakness, the dose should not 
exceed 10 grains. Chloralose may be given in 
5-grain doses in wafers or in hot milk. See 
Lambert Treatment for Narcotic Addiction. 
OPOTHERAPY.-See Organotherapy. 
OPSONIC INDEX.-See Opsonin Therapy; 
Serum Therapy; Vaccine Therapy. 
OPSONIN THERAPY.-Substances in the blood 
serum that prepare bacteria for phagocytosis are 
known as opsonins. They are destroyed by heat- 
ing to 60° C. The opsonic index denotes the rela- 
tive power of the leukocytes to devour pathogenic 
organisms and is determined by mixing equal 
volumes of washed leukocytes, patient's serum, 
and emulsion of the organism in question. A 
similar mixture is made with the substitution of 
normal control serum instead of the patient's 
serum. After the mixtures have been in the incu- 
bator 15 minutes at 37° C., a drop of each is 
placed on a slide; a smear is made and stained. 
The average number of organisms in a definite 
number of leukocytes (i. e., 50 or 100) represents 
the bacillary index, the average number in each 
leukocyte indicates the phagocytic index; the 
patient's value divided by the normal control 
gives the opsonic index. 
In order to fortify the resistance, i. e., the phago- 
cytic power, of the patient, which is often weak- OPTIC NERVE ATROPHY 
OPTIC NEURITIS 
ened by infection, substances known as bacterial 
vaccines are introduced to reinforce the opsonins. 
An inoculation of dead cultures of the organism in 
question is made, the aim being to raise the opsonic 
index. 
After each injection there is a fall in the opsonic 
content, called by Wright the "negative phase," 
then follows a rise, "positive phase," evidenced by 
improvement in the condition of the patient. The 
injection should be made only in the latter phase. 
See Vaccine Therapy. 
OPTIC NERVE ATROPHY. Causes.-The vast 
majority of cases are postneuritic-that is, follow- 
ing some inflammation of the optic nerve. Most 
cases are due to some disease of the brain or spinal 
cord, especially of syphilitic origin. Of the cerebral 
diseases might be mentioned disseminated sclero- 
sis, progressive paralysis, and general paralysis; 
of the diseases of the spinal cord, locomotor ataxia 
is a prominent cause. Mechanic pressure from 
tumors, traumatism, embolus in the central artery, 
cutting off the blood supply, and the toxic agents, 
causing retrobulbar neuritis, lead to optic atrophy. 
Blindness, or amblyopia following severe hemor- 
rhages, is supposed to be due to atrophy of the 
optic nerve. Sexual abuse, "catching cold," 
physical and mental excesses, have all been set 
down as causes. 
Symptoms and Diagnosis.-The patient notices 
an early disturbance of vision, consisting of dimi- 
nution in the central acuity, concentric contraction 
of the visual field, both for white and colors, and 
irregular scotomas. There is no pain, and seldom 
photophobia. Of the colors, green is first lost, and 
blue last; light-sense is longest retained. The 
ophthalmoscopic appearances vary with the cause. 
If the atrophy is subsequent to papillitis, the disc is 
increased in size, and there is more or less oblitera- 
tion of its outline and distention of the veins. In 
simple atrophy instead of the rosy, healthy hue of 
the normal disc, the papilla may be grayish-blue or 
quite white. The outlines have a striking sharp- 
ness, which gives the shining disc its characteristic 
appearance. The disc appears sunken and ex- 
cavated, and allows the network of the lamina 
cribrosa to be seen through the spaces left open by 
the disappearance of the nerve-fibers. The vessels 
diminish in size, and the capillaries of the papilla 
are no longer visible. 
Prognosis is serious. The probability of retain- 
ing the vision yet left is small, and the result is 
usually total blindness. 
Treatment should be directed to the cause; 
constant, increasing doses of strychnin should be 
given, orally or hypodermically, and the continu- 
ous electric current should be applied until it is 
found to be of no avail. Good results have 
recently been reported from the combined use of 
mercuric chlorid and nitroglycerin. 
OPTIC NEURITIS. Synonyms.-Choked disc, 
papillitis, neuroretinitis. Choked disc is so called 
on account of the interference of return of blood 
through retinal veins by pressure from swelling at 
this point. Papillitis generally describes an in- 
flammation limited to the intraocular head of the 
optic nerve, although in all probability, in the 
majority of cases, the nerve is affected throughout 
its entire length. There is less swelling than in 
choked disc, the visual disturbance appears earlier, 
and the disease leads to atrophy and blindness 
more frequently than does choked disc. Neuro- 
retinitis and papilloretinitis are terms used to de- 
scribe an inflammation which involves the retina as 
well as the optic nerve. It is characterized by 
hemorrhages, patches of fatty degeneration that 
appear as white spots, deposition of pigment, etc., 
similar to the changes in albuminuric retinitis. 
Causes.-The condition often called choked disc 
may be due to traumatism, but is usually the re- 
sult of a brain tumor, and is commonly bilateral. 
Tumors of the cerebellum and those at the base of 
the brain pressing upon the sinuses are most likely 
to be followed by choked disc. Some form of 
optic neuritis is said to accompany 90 percent of all 
cases of brain tumor. If unilateral, the disease is 
probably caused by a tumor in the orbit. Other 
intracranial diseases causing inflammation of the 
optic nerve are; Tuberculous basilar meningitis 
of children, epidemic cerebrospinal meningitis- 
in fact, meningitis from other infectious diseases or 
from any suppurative origin. Infectious diseases, 
syphilis, lead-poisoning, and other systemic affec- 
tions may directly cause optic neuritis. Tumors or 
diseases of the orbit may have the same effect. 
Traumatism and inflammation of surrounding 
tissues are also causes. 
Pathologic Anatomy.-Cerebral tumors interfere 
with the circulation and distribution of sub- 
arachnoid fluid in the lymph-spaces. The sheath 
of the optic nerve becomes much swollen and 
pyriform. It is supposed that the bacilli of the 
causative meningitis act directly upon the nerve- 
head. 
The line of distinction between retinitis and 
neuroretinitis is so slight that we can probably 
associate closely the causes of the former with those 
of the latter; however, in albuminuric neuroretin- 
itis the greatest changes are in the retina rather 
than in the nerve-head, and the urinary tests are 
quite indicative. Cases of inflammation of the 
optic nerve in which the cause is unknown are 
sometimes seen. Occasionally, several members 
of a family-the males particularly-and of 
apparently healthy parents, are attacked between 
the eighteenth and twenty-fourth years by a bilat- 
eral optic neuritis. In other cases, "catching cold," 
suppression of the menses, lactation, etc., are 
given as causes. In such cases there must be a 
suspicion that there was latent inflammation which 
became prominent under the conditions mentioned, 
and was not directly due to them. 
Symptoms and Diagnosis.-The systemic condi- 
tion is often simultaneously affected. The princi- 
pal ocular symptom is impairment of vision, gradu- 
ally passing into total blindness. In the early 
stages of choked disc vision is not markedly im- 
paired. Particularly typical are diminution of 
central visual acuity, unsymmetric contraction of 
the visual field, and impaired color-sense. The 
ophthalmoscopic appearance of choked disc is a 
swelling and opacity in the disc and its immediate 
neighborhood. That the papilla is larger than OPTIC NEURITIS, RETROBULBAR 
normal and projects into the vitreous may be proved 
by the parallax test. The papilla, while under- 
going inflammation, has what has been called a 
woolly appearance, together with swelling and con- 
gestion. The small vessels of the disc are dilated, 
so that many of them are visible, unless masked by 
excessive edema. There may be numerous capil- 
lary hemorrhages in the nerve-head. The retinal 
arteries are diminished in size, and the veins are 
swollen and tortuous. The edges of the disc are 
lost, and a striated flame-like or grayish haziness 
spreads over the disc into the adjoining retina, 
nearly equal on all sides. In severe forms there 
are diffuse retinal hemorrhages and, perhaps, 
macular changes resembling albuminuric retinitis. 
In addition to the presence of choked disc, the 
discovery of hemianopsia and the use of Wernicke's 
sign will aid in the diagnosis of cerebral growth. 
In the interstitial or descending neuritis the disc 
is not swollen as in choked disc; it is dull and 
edematous looking. Vision is usually more and 
sooner affected, owing to the greater length of 
nerve structure involved. 
Prognosis.-The course is usually chronic, 
finally ending in optic nerve atrophy. Of course, 
the prognosis is affected by the cause. Cerebral 
tumors are usually fatal in a short time. The 
various forms of meningitis are always serious. 
Restoration of vision is doubtful; there is little 
hope of regaining lost visual power. However, 
cures, with restoration of normal visual acuity, 
and cures of amblyopia of every degree, have been 
reported. 
Treatment is naturally directed to the cause. 
If the cerebral tumor can be located, surgical in- 
terference may be of value. A syphilitic gumma 
will yield to mercury and potassium iodid. If no 
cause is discernible, diaphoresis, the mercurials 
and iodids, and tonics may be tried. Blood-letting 
from the temporal region has been reported of value. 
Possibly mild cases recover spontaneously. If 
there is reason to suspect that the neuritis is 
orbital in origin, systemic teatment will prove 
of little value; and in well-defined malignant 
orbital disease immediate enucleation is im- 
perative. 
OPTIC NEURITIS, RETROBULBAR.-Inflam- 
mation of the optic nerve beyond the eyeball, in 
which the disc is not involved at first, papillitis 
arising in the advanced stage. 
Causes.-Acute retrobulbar neuritis is caused by 
exposure to cold, acute infectious diseases, sudden 
cessation of the menses, and any condition which 
leads to a sudden exudation into the sheath of the 
optic nerve. The most common cause of the 
chronic form is excessive use of tobacco and alco- 
hol, although lead-poisoning, syphilis, quinin, and 
other toxic agents may produce it. As a rule, both 
tobacco and alcohol are simultaneously used to 
excess, and act conjointly. The disease is often 
called tobacco or alcohol amblyopia, or toxic or in- 
toxication amblyopia, although many authors dis- 
tinguish between intoxication amblyopia and re- 
trobulbar neuritis from other causes. It has re- 
cently been suggested that the central amblyopia is 
due to primary rather than to secondary macular 
disease-that is, that the- disease starts in the 
macula and ascends the central fibers of the 
optic nerve. 
Symptoms.-In the acute disease total blindness 
results in a few days, and there is often pain in the 
eye, increased by movement or pressure. The 
ophthalmoscope reveals a papillitis of moderate 
severity. In the more common chronic disease 
the chief symptom is slowly diminishing central 
vision. The patient complains that he sees indis- 
tinctly, especially in bright light, and that his 
vision improves at sundown. This is explained 
by the dilatation of the pupil as day light fades, 
and consequent stimulation of the unaffected 
perimacular region by the increased illumination. 
Examination with the perimeter shows a central 
scotoma, at first for color, and finally for light. 
At the onset the field of vision remains nearly 
normal, and only begins to be obliterated when 
fixation becomes impossible, and nystagmus re- 
sults. With the ophthalmoscope there is first seen 
slight hyperemia of the disc, and later a grayish- 
white discoloration of the temporal halves of the 
papillae. The outlines are obscured, the veins are 
enlarged, and the arteries are diminished in size. 
Prognosis may be considered favorable if the 
disease has not progressed to atrophy, and if the 
patient can be made to stop drinking and smoking; 
but relapses are likely to occur whenever the absti- 
nence is suspended. 
Treatment.-In the acute form general blood- 
letting, active diaphoresis, and other antiphlogis- 
tic measures are indicated. In chronic cases 
abstinence from tobacco and alcohol must be 
enforced, and strychnin administered in increasing 
doses. If syphilitic, the disease yields to the 
mercurials and iodids. Any other discoverable 
cause should be treated according to the indications. 
ORANGE.-See Aurantium. 
ORBIT, DISEASES.-Periostitis is an inflamma- 
tion of the periosteal lining of the orbit, particu- 
larly prevalent in scrofulous and syphilitic patients. 
The inflammation may be so extensive as to in- 
volve the frontal sinuses and produce necrosis of 
the underlying bones. A blow or a fall is usually 
the exciting cause. 
The symptoms are dull pain, swelling and edema 
of the skin surrounding the orbital edge, and, if 
necrosis has taken place, a fistula discharging foul 
pus and bony debris. Cicatrization of the fistula 
may lead to ectropion. The eyeball is rarely 
involved. 
Treatment consists of leeches to the temple, cold 
compresses, and, if the patient is syphilitic, the 
administration of mercurials and iodids. If the 
disease reaches a suppurative stage, antiseptic 
poultices, incision, and drainage are indicated. 
Orbital cellulitis, or inflammation of the connec- 
tive tissue of the orbit, is due to periostitis or to 
any suppurative or inflammatory process in the 
vicinity of the eye; even inflammation about the 
roots of the teeth may cause it. Erysipelas, 
anthrax, and pyemia may result in metastatic 
orbital abscess; and, finally, infection after injury 
to the orbit or its contents is a cause. 
The symptoms are pain, fever, general prostra- 
ORBIT, DISEASES ORCHITIC EXTRACT 
ORGANOTHERAPY 
tion, swelling and redness of the lids, edema and 
increased tension of the conjunctiva and lids, 
exophthalmos, fixation of the eyeball in a straight 
or deviating position, causing visual disturbance, 
and, after the pus escapes, a discharge from the 
orbit. In unfavorable cases panophthalmitis may 
ensue. Metastatic abscesses generally lead to 
death. Extension into the cranium is always to 
be feared. 
Treatment consists in prompt incision-prefer- 
ably at a spot showing signs of pointing-drain- 
age, and antiseptic irrigation. 
Injuries to the orbit may cause fracture of the 
bony wall or laceration of the soft parts. Foreign 
bodies may be received and retained in the orbit 
for varying periods of 'time. They may escape 
into the nasal cavities, or they may cause orbital 
inflammation, and even death. Luxation of the 
globe is generally produced by a wedge-shaped 
foreign body crow'ding between the eyeball and 
the orbit. Formerly, what was called "gouging" 
was resorted to by contestants in brutal fights, 
the object being to dislocate the eyeball from its 
socket with the point of the thumb. The danger 
is blindness from laceration or overstretching of 
the optic nerve. 
Fracture of the orbit may be detected by palpa- 
tion. If the neighboring sinuses are opened, there 
will be much emphysema about the lids, made 
worse by blowing the nose. There is late appear- 
ance (2 or 3 days) of extravasation and ecchymosis 
of the lids. If the optic foramen is involved, there 
is, sooner or later, blindness from pressure or 
injury of the optic nerve. When fracture of the 
orbit produces enough hemorrhage to cause exoph- 
thalmos, the prognosis is grave. 
Treatment.-After orbital injuries the affected 
parts should be thoroughly disinfected and foreign 
bodies removed. The proximity of the brain to 
the orbit renders the prognosis doubtful in exten- 
sive fractures or infected wounds. Rest and 
cooling compresses are indicated. In luxation 
vision may be lost through stretching of the optic 
nerve, but may return after reposition of the eye- 
ball and retention with a pressure-bandage. If 
the lids are closed tightly behind the globe, pre- 
venting replacement, the external canthus should 
be divided at once. The longer the eyeball is 
dislocated, the worse the effect upon vision. 
Tumors of the orbit cause exophthalmos in the 
direction of pressure. The other symptoms are 
disturbance of motility and vision and pain, all of 
which vary according to the size and malignancy 
of the tumor. The chief tumors are osteoma and 
encephalocele of the orbital wall; tumors of the 
optic nerve; and sarcoma, cysts, and vascular 
tumors arising in the neighboring cellular tissue. 
A genuine orbital sarcoma is extremely rare, and 
carcinoma never originates in the orbit proper. 
All orbital tumors of any considerable size or 
malignancy should be removed after enuclea- 
tion of the eye. There is little hope of cure of 
encephalocele. 
ORCHITIC EXTRACT.-See Testicular 
Extract. 
ORCHITIS.-See Testicle (Inflammation). 
ORGANOTHERAPY.-The treatment of dis- 
eases by the administration of animal organs, or 
extracts prepared from them. Although organo- 
therapy has existed in some form since the most 
ancient times, the method as now practised is of 
recent origin. Brown-Sequard, in 1889, suggested 
the employment of testicular juice in the treat- 
ment of the mental and physical deterioration 
incident to old age. Experiments which he had 
made upon himself had, he reported, yielded the 
most brilliant results. Physicians in different 
parts of France subsequently tested the properties 
of Brown-Sequard's extract, and found its dyna- 
mogenic action beneficial in diseases attended 
with debility, especially in senile changes, in 
pulmonary tuberculosis, leprosy, locomotor ataxia, 
general paralysis, and anemia. Paul, in 1892, 
under the name of "nervous transfusion," advo- 
cated the hypodermic use of an extract of sheep's 
brains in conditions of neurasthenia. The method 
of preparation of the various extracts as employed 
in France is that suggested by d'Arsonval. The 
organ is removed, with all possible antiseptic pre- 
cautions, and is cut into small pieces of about 1 
c.c. The segments are covered with pure glycerin 
and allowed to macerate for 24 hours. Before 
filtering, 2 or 3 parts of distilled water are added. 
Sterilization is accomplished by means of carbonic 
acid gas under pressure. The first step toward a 
rational application of the method of organo- 
therapy was the subcutaneous transplantation of 
pieces of thyroid gland in cases of myxedema and 
cachexia strumipriva by Horsley and Kocher, and 
later the employment of extract of sheep's thyroid 
in myxedema, the credit of which belongs to 
G. R. Murray, of Newcastle, England. Since Mur- 
ray's announcement, in 1891, the method has been 
extensively tested in England and elsewhere; 
many cases of myxedema have been reported as 
improved, and not a few cured. Gratifying results 
have also been achieved in sporadic cretinism, and 
in psoriasis and other chronic affections of the 
skin. Various preparations of the thyroid gland 
have been employed-e. g., glycerin extracts, dry 
extracts in powder, and, finally, the uncooked or 
partially cooked gland has been used. In the 
particular case of myxedema neither the kind of 
preparation nor the mode of administration seems 
to be of much importance. The results have been 
practically the same whether a liquid extract was 
given by hypodermic injection, or a dry extract 
was administered by the mouth. The fresh gland, 
slightly fried and seasoned, has also been used, 
and at present is preferred by many. The success 
attending thyroid therapy in myxedema has led 
to the employment of many other organic extracts 
in diseases of corresponding organs. Extracts 
have been prepared from nearly every organ in the 
animal body; thus there are on the market: Cere- 
brin, from the brain; medullin or myelin, from the 
cord; cardin, from the heart; musculin, from mus- 
cles; ossin, from bones; renin, from the kidneys; 
gastrin, from the stomach; pancreatin, from the 
pancreas; ovarin, from the ovary, and testin, from 
the testis. Pituitary extract has sometimes 
proved beneficial in acromegaly. Splenic extract ORPHOL 
OVARIOTOMY 
has been used with some success in exophthalmic 
goiter, and in insanity due to physical exhaus- 
tion. Thymus extract appears beneficial in leuko- 
cythemia, chlorosis, anemia, pernicious anemia, 
" status thymicus." Brain-extract has been re- 
ported as beneficial in various organic and func- 
tional diseases of the nervous system, such as 
locomotor ataxia, bulbar palsy, general paralysis 
of the insane; also in epilepsy, neurasthenia, mi- 
graine, hysteria, hebephrenia, and other conditions. 
Heart-extract is recommended for cases of nervous 
prostration. It is said to raise the blood-pressure, 
augment the quantity of urine, and increase the 
number of red blood-corpuscles. In diseases of 
the muscular system muscle-extract is also reported 
as of value. Extract of pancreas, containing the 
active ferments of the gland, has been adminis- 
tered with doubtful success in certain cases of 
diabetes mellitus, which disease, as is well known, 
is sometimes dependent upon morbid changes in 
the pancreas. Of all the extracts, that of the 
thyroid gland is still the one most successfully 
employed. Its use is not confined to the two 
diseases mentioned-myxedema and cretinism; 
it seems to be an efficient galactagog and is use- 
ful in promoting consolidation of obstinate frac- 
tures; it has also proved useful in diseases of 
the skin, in leukemia, and affections of the 
nervous system, both organic and functional, 
endometritis, menorrhagia, uterine fibroma and 
carcinoma, lupus, ozena, obstinate leg ulcers, pro- 
gressive myopathy, simple goiter; in exophthalmic 
goiter, and diabetes mellitus and cases presenting 
much emaciation it is contraindicated. See Thy- 
roid Treatment. 
ORPHOL.-Bismuth beta-naphtholate. An in- 
testinal antiseptic. Dose, 5 to 20 grains in honey 
or milk. See Bismuth. 
ORRHOTHERAPY.-See Serum Therapy. 
ORTHOFORM.-It has no chemical relation to 
cocain which it resembles only in its action on the 
sensory nerve terminations. It occurs as a white, 
crystalline, odorless and tasteless powder, almost 
insoluble in water. It is efficient as a local anes- 
thetic only when it comes in contact with exposed 
sensory nerves, and has been used chiefly as a 
dusting powder or ointment for painful abrasions, 
ulcers or burns. Applied in powder to raw sur- 
faces, as burns, and excoriated nipples, it has 
frequently produced local gangrene. Internally 
it has been given in doses of 8 to 15 grains for the 
pain of gastric ulcer and cancer. It does not 
reHeve the pain of simple gastralgia, and hence it 
has been employed as a test for gastric ulcer. A 
saturated solution in collodion may be used as a 
paint, and an emulsion in glycerin is employed 
during operations within the uterus. The hydro- 
chloric! is more soluble in water and may be used 
for internal administration or urethral injection, 
but is too acid for hypodermic injection or eye 
application. Its incompatibles are antipyrin, 
bismuth subnitrate, and silver nitrate. 
ORTHOPEDIC SURGERY.-See Genu, Hip- 
joint Disease, Talipes, etc. 
OSMIDROSIS.-See Bromidrosis; Sweat- 
gland. 
OSMIUM TETROXID (Osmic Acid).-Obtained 
by the action of nitrohydrochloric acid on osmium. 
In persistent neuralgia it is injected into the nerve 
in doses of 1/2 to 1 c.c. of a fresh 1 to 2 percent 
solution. The cure is rarely permanent. It is 
contraindicated in renal disease. 
OSTEOARTHRITIS.-See Joints (Diseases). 
OSTEOARTHROPATHY, HYPERTROPHIC 
PULMONARY.-A disease first described by Marie, 
characterized by a bulbous enlargement of the 
terminal phalanges of the fingers and toes, a thick- 
ening of the articular ends of the bones, a peculiar 
curvation of the nails, and an enlargement of the 
lower jaw. According to Marie, the condition is 
usually associated with disease of the lungs or 
pleura, and results from the absorption of toxic 
products from the diseased foci. The disease is 
not allied to akromegaly. See Bone (Diseases), 
Joints (Diseases). 
OSTEOCLASIS.-See Genu Valgum. 
OSTEOMA.-A bony tumor; exostosis. See 
Tumors, Bone (Diseases). 
OSTEOMALACIA.-Softening of bone from loss 
of its earthy constituents, occurring in adults, 
especially in females and in the course of preg- 
nancy. The true cause of the disease is not 
known; by some it is considered to be infectious, 
but this view is not proved. See Bone (Diseases). 
OSTEOMYELITIS.-See Bone (Diseases). 
OSTEOPERIOSTITIS.-See Bone (Diseases). 
OSTEOSARCOMA.-See Bone (Diseases). 
OSTITIS.-See Bone (Diseases). 
OSTITIS DEFORMANS (Paget's Disease).-A 
rare senile disease characterized by kyphosis of the 
spine, marked enlargement of the cranial part of 
the head, enlargement and deformity of the 
clavicles, and of the long bones of the extremities 
due to a rarefying ostitis. The abdomen pro- 
trudes; the ribs fall in and cause dyspnea; 
neuralgic pains are present; and there is some 
muscular atrophy, but the bones of the face, hands, 
and feet remain practically normal. 
OTITIS.-See Ear (Diseases). 
OTOSCOPE.-An instrument for examining the 
ear. What is ordinarily called and used as an 
otoscope is a rubber tube, one extremity of which 
is inserted into the ear of the subject, and the other 
extremity into the ear of the examiner, a current 
of air being passed by means of a Politzer bag and 
a eustachian catheter through the middle ear. In 
case of tympanic perforation the rushing sound 
made by the passing air is audible to the examiner. 
See Ear (Examination). 
OVARIAN EXTRACT.-The substance of the 
ovaries has been administered with some benefit 
in the nervous manifestations and pathologic 
conditions which occur when the ovarian functions 
are partially or wholly arrested, as in cirrhosis or 
malignant disease thereof, or after the operation 
of ovariotomy. It is said to be of use in cases of 
depression or other mental disturbance coincident 
with the climacteric, to relieve ovarian congestion 
and neuralgia, and to be efficient in the treatment 
of delayed or scanty menstruation. See Organo- 
therapy. 
OVARIOTOMY.-The removal of the ovaries and OVARY, DISEASES 
OVARY, DISEASES 
fallopian tubes. This operation is usually effected 
through an incision in the abdominal wall. Some 
operators, under certain circumstances, prefer the 
vaginal route. 
The operation is performed for diseased condi- 
tions of the tubes and ovaries; for extrauterine 
pregnancy; for cysts and tumors of the ovary; and 
for cysts of the parovarium. See Fallopian 
Tubes;Ovary (Diseases). 
The removal of the tubes and ovaries was form- 
erly advised in certain cases of fibroid tumors of 
the uterus to bring about a premature menopause, 
but at present the operation is rarely if ever done 
for that purpose. See Uterus (Fibroid Tumors). 
OVARY, DISEASES. Hernia.-Descent of the 
ovary into the inguinal canal, or even into the 
labium majus, has been noted occasionally. There 
may be no symptoms present, or there may be pain, 
which is much increased at the menstrual period. 
The characteristic sickening pain on pressure, the 
increase in size at the menstrual period, and biman- 
ual examination will confirm the diagnosis. 
Treatment should consist in replacing the ovary 
and sac, after which it should be kept in place by a 
properly applied truss. If the ovary is diseased, 
it should be removed. 
Prolapse.-Downward displacement of the 
ovary without displacement of the uterus and 
tubes. For displacement of the ovary accompany- 
ing displacement of the uterus, see Uterus. 
The principal cause of prolapse of the ovary is 
some condition which increases its weight, such as 
prolonged congestion, inflammation, and subinvolu- 
tion. Elongation and stretching of the ligaments 
of the ovary may result in prolapse. It some- 
times occurs as the result of a violent strain or sud- 
den effort. 
The symptoms of ovarian prolapse are usually 
well marked and occasionally severe. Pain is the 
most constant symptom. It is increased by any 
movement or straining effort, such as walking or 
defecation. It is always more severe at the men- 
strual periods. The pain is dull and aching in 
character, and usually extends down the thigh. 
Associated with the pain are frequently found 
such symptoms as nausea and indigestion, head- 
ache, and nervous disturbances. Bimanual exam- 
ination will usually reveal the ovary in its abnor- 
mal position. It is enlarged and excessively ten- 
der, the slightest touch causing intense .pain. 
Occasionally it may be pushed in place by the 
examining finger, when it will remain there until 
the patient assumes the erect posture, or until she 
coughs or strains. 
The treatment of ovarian prolapse will depend 
upon the condition which causes it. Prolapse of 
the ovary accompanying displacement or subin- 
volution of the uterus will usually be cured by 
restoring the uterus to a normal condition. In 
uncomplicated cases of ovarian prolapse the 
patient should be advised to assume the knee- 
chest position 2 or 3 times daily; the vaginal orifice 
should be opened so that its walls may be dis- 
tended by air, and the woman should remain in 
this position for 5 or 10 minutes if possible, after 
which she should lie in the lateroabdominal position 
for a time. This restores the ovary to its normal 
position, and, in time, if efforts are made to reduce 
the size of the ovary and to secure contraction of 
its ligaments, it may remain there. 
Return of the ovary to its normal size may be 
secured by relieving pelvic congestion. This is 
best accomplished by the use of saline laxatives; 
by frequent vaginal douches of hot water; by 
painting the vaginal vaults and cervix with tinc- 
ture of iodin, and by the use of glycerin or glycerin 
and ichthyol tampons. If the ovary is diseased, 
or if it is bound down in its abnormal position by 
extensive adhesions, it will have to be removed. 
Occasionally, if the ovary is healthy, the abdomen 
should be opened and the ovary fixed in its proper 
position. Sometimes this may be accomplished 
by shortening the round ligaments or by ventro- 
fixation. In other cases the infundibulopelvic 
ligaments should be shortened or the outer end 
of the ovary should be attached to the broad 
ligament at its upper posterior part. However, 
the ovary is ordinarily diseased. 
Acute inflammation of the ovary (oophoritis) is 
usually the result of extension of inflammation 
from the tube. It is particularly apt to occur as 
the result of gonorrheal salpingitis or puerperal 
sepsis. It may occur as a complication of the 
eruptive fevers. 
The symptoms of acute oophoritis are pain in the 
ovarian region, accompanied by rise of tempera- 
ture and rapid pulse. There may be nausea and 
vomiting. Bimanual examination will reveal 
the enlarged tender ovaries. 
The treatment consists of rest in bed, vaginal 
douches of hot water, hot fomentations over the 
lower abdomen, and free purgation. If the symp- 
toms increase in severity and if suppuration 
occurs, laparotomy must be performed and the 
diseased structures removed. 
Chronic inflammation of the ovary occurs in 
two forms. The follicular part of the ovary may 
be particularly involved, giving rise to the forma- 
tion of numerous little cysts underneath the cap- 
sule, when it is called cystic oophoritis; or there 
may be an increase in the connective-tissue ele- 
ment of the ovary, diminishing its size and render- 
ing it paler and harder, when it is called cirrhotic 
oophoritis. Chronic oophoritis is usually bilateral. 
The condition may persist after an acute attack, 
or it may be chronic from the beginning as the 
result of a mild form of infection transmitted from 
the tubes. Prolapse of the ovary, excessive sex- 
ual connection, and celibacy may be mentioned as 
less important causes. 
Symptoms.-The most important symptom of 
chronic oophoritis is pain. It is worse just before 
the menstrual period, and is usually relieved after 
the flow is well established. The pain is exagger- 
ated by the erect posture and by exercise or move- 
ment of any kind. Associated with the pain are 
commonly menorrhagia and reflex nervous dis- 
turbances. Bimanual examination will reveal 
the altered condition of the ovary Accompany- 
ing it there will usually be found displacement of 
the uterus and disease of the tubes. 
The treatment of chronic oophoritis is palliative OVARY, DISEASES 
OVARY, DISEASES 
or operative. Palliative treatment may prove 
successful when there is no accompanying disease 
of the tubes or uterus. It consists of prolonged 
rest in bed, mild purgation, hot vaginal injections, 
applications of tincture of iodin to the vaginal 
vaults and cervix, and the use of glycerin tampons. 
It may be necessary to begin the treatment by the 
repair of a lacerated cervix or perineum, or by 
a thorough curettage. Sexual connection must 
be prohibited during the treatment. If there 
is accompanying disease of the uterus and tubes, 
or if, after the foregoing treatment, the pain 
should persist or return, oophorectomy should be 
performed. 
The relief afforded by palliative treatment is 
rarely permanent when this plan is pursued to tide 
the woman over the menopause. Palliative 
treatment is only applicable to women who can 
afford to be chronic invalids. 
Cystic Tumors.-There are 3 classes of cystic 
tumors of the ovary: 
1. Oophoritic cysts, which arise from the paren- 
chyma of the ovary-the oophoron. 
2. Paroophoritic cysts, which arise from the hilum 
of the ovary-the paroophoron. 
3. Parovarian cysts, which arise from the paro- 
varium. 
Cysts of this last class while they do not arise 
directly from the ovary, have so close a connection 
with it that they may properly be classed as ovarian 
cysts. 
Oophoritic cysts may be subdivided into (1) 
cysts of the Graafian follicles, (2) cysts of the cor- 
pus luteum, and (c) multilocular cysts. 
Cysts of the Graafian follicles arise from disten- 
tion and coalescence of the ovarian follicles. Such 
cysts may consist of a number of distended follicles 
or of one large follicle. They rarely attain a large 
size, usually ranging from that of a walnut to an 
egg. The wall of the cyst is thin and smooth, and 
is lined with epithelium, either columnar or strati- 
fied. It is filled with a straw-colored serum, hav- 
ing a specific gravity from about 1005 to 1020. 
The condition is usually due to thickening of the 
capsule of the ovary, which prevents rupture and 
discharge of the Graafian follicle. These cysts are, 
therefore, retention cysts. Occasionally hemor- 
rhage will take place in the cyst, when it will be 
found filled with a dark, chocolate-colored fluid. 
Cysts of the corpus luteum are a variety of follicu- 
lar cysts. They have a peculiar light-yellow color, 
and almost never exceed a walnut in size. They 
are caused by degeneration and distention of a 
corpus luteum. 
The symptoms of the two varieties of cysts just 
described are not marked. There is usually some 
ovarian pain, and thefe may be menorrhagia or 
metrorrhagia. 
The diagnosis must be made by a bimanual 
examination, which will reveal the enlargement of 
the ovary. 
Unless the pain is intense, palliative treatment is 
indicated. Should the patient suffer severely, the 
ovary and probably the corresponding tube should 
be removed. If there is but one cystic cavity in 
the ovary, it should be incised, its contents evacu- 
ated, and the severed edges whipped over with fine 
catgut. It should be remembered that these cysts 
are limited in growth, and will never give rise to 
dangerous symptoms. 
Multilocular cysts are cysts of unlimited growth. 
They are supposed to originate in a degeneration 
of the ducts of Pfl tiger. The wall of these cysts is 
thick and strong, and is composed mainly of 
fibrous connective tissue. It has usually 3 layers, 
which are most distinct in the neighborhood of the 
pedicle. These cysts are intraperitoneal in growth, 
and are attached to the ovary by a distinct pedicle, 
through which it obtains its nourishment. As 
these cysts increase in size, the septums between 
the loculi may be absorbed, so that, although the 
cyst is always multilocular at first, it may finally 
become unilocular. Traces of these septums are, 
however, always visible. 
These cysts may vary in size from that of a fetal 
head to a tumor weighing as much as 200 pounds. 
The contents are usually syrupy in consistency and 
light in color, and may be dark brown or black. 
The specific gravity is always above 1010. If the 
lining membrane is epithelium, the tumors are 
known as simple multilocular cysts; if mucous 
membrane, they are called glandular cysts; if 
presenting the characteristics of the skin and its 
appendages, they are known as dermoid cysts. 
Paroophoritic cysts are also called papillary cysts 
of the ovary. They arise from the hilum of the 
ovary, and probably originate in the remains of the 
Wolffian body. Since they grow from the hilum, 
or attached portion of the ovary, they are usually 
extraperitoneal, forcing their way between the 
layers of the broad ligament. As a rule, these 
cysts are not attached by a distinct pedicle. 
The lining membrane is cylindrical epithelium, 
sometimes ciliated. Upon the interior of the cyst 
are scattered warty or papillary growths, from 
which it derives its name. These growths are 
usually pink in color and are very vascular, bleed- 
ing upon the slightest touch. They show a 
marked tendency to perforate the cyst wall, 
causing secondary papillary growths to appear 
on any organ with which they come in contact. 
The contents are usually a clear, watery serum, 
with a specific gravity of from 1005 to 1040. 
These ■ cysts are rarer than the multilocular 
cysts; they do not grow so rapidly, nor do they 
become so large; and they are frequently bilateral. 
Parovarian cysts may be subdivided into (1) 
cysts of Kobelt's tubes and (2) cysts of the vertical 
tubes. They originate in the parovarium, the 
remains of a fetal structure lying in the mesosal- 
pinx between the tube and ovary. Cysts of 
Kobelt's tubes are small pedunculated cysts about 
the size of a pea. They originate in the outer 
series of tubules of the parovarium. They are not 
important pathologically, since they cause no dis- 
turbance. They resemble very much the hydatid 
of Morgagni. 
Cysts of the vertical tubes are of unlimited 
growth. They develop between the layers of the 
broad ligament, and are therefore extraperitoneal. 
The layers of the broad ligament are widely sepa- 
rated, and the fallopian tube is greatly elongated. OVARY, DISEASES 
OXALIC ACID 
The ovary is not affected unless the cyst becomes 
large. Cysts of the vertical tubes may be either 
simple or papillary. The papillary varieties are 
rare, and present the same characteristics as the 
cysts of the paroophoron. The wall of the paro- 
varian cyst is thin, and its contents are a clear 
serum with a specific gravity below 1010. 
These cysts are small in size, slow in growth, and 
are almost invariably unilocular and unilateral. 
The following tables will recall the classification 
and characteristics of the cystic tumors of the 
ovaries: 
generally be felt by the vaginal finger. Ovarian 
cysts may be mistaken for ascites, pregnancy, 
fibroid tumors of the uterus, and a fat abdominal 
wall with tympanitic distention of the intestines. 
The prognosis is favorable if operation is per- 
formed. Ovarian cysts are not malignant in 
character, yet they frequently cause death by 
their rapid growth and great size. Pressure upon 
the uterus, with resulting kidney-disease, is 
another frequent cause of death. Other causes of 
death may be the various complications to which 
cysts are liable, such as inflammation and suppu- 
ration, torsion of the pedicle, hemorrhage, and 
rupture. Papillary cysts are particularly danger- 
ous on account of their liability to rupture, with 
the formation of secondary papillary growths. 
The treatment of ovarian cysts is operative. 
Even though the tumor has given no symptoms, 
it should be removed. Serious complications may 
arise at any time which will render its removal 
difficult, or which will destroy the patient in a few 
days. Tapping should not be resorted to on 
account of the many dangers which attend it. 
Solid Tumors.-Solid tumors of the ovary are 
rare. They are found in about 5 percent of all 
cases of ovarian tumors. The most important 
are fibroma, myoma, sarcoma, carcinoma, and 
papilloma. 
The treatment is removal as soon as diagnosed. 
OVERLYING.-An accident which not infre- 
quently happens to young children, and in which 
they are suffocated. It is usually the fault of 
drunken parents who, in sleep, roll over their 
infants. Evidence that a child has really died 
from this Cause is afforded by (1) the postmortem 
appearance of death from asphyxia; (2) the ab- 
sence of any other mortal disease, and (3) absence 
of evidence of any cause of asyphxia other than 
overlying. The statement that a child has been 
overlain should be received with caution. It is 
reasonable to suppose a child would escape from 
a suffocating position beneath bedclothes, or the 
body of another, or succeed by crying or strug- 
gling in awaking the nurse or another. A medical 
witness must consider all points before charging 
carelessness in this, or, on the other hand, allowing 
an act of wilful murder to pass under the guise of 
accidental death. 
OXALIC ACID. (COOH)2.-A colorless, crys- 
talline solid, occurring in many plants as potassium 
oxalate. It is soluble in 9 parts of water and 
more soluble in alcohol. It is a respiratory 
depressant in 1/2 grain dose, and is a violent 
poison in large dose. It is serviceable in amenor- 
rhea, in 1/2 to 3/4 grain dose, and it is classified 
as a direct emmenagog. It is commonly known 
as "salts of lemon" or of "sorrel," and is used for 
removing ink-stains; when taken internally, it 
results in poisoning. If a person immediately 
after swallowing a solution of a crystalline salt 
which tasted purely and strongly acid is attacked 
with burning sensation in the throat and then in 
the stomach, vomiting, particularly of bloody 
matter, imperceptible pulse, and excessive languor, 
and dies in half an hour, or still more in 20, 15, 
or 10 minutes, there is strong reason to believe that 
CYSTIC TUMORS OF THE OVARY. 
1. Cysts of the 
Graafian fol- 
licle. 
Blood cysts. 
1. Cysts of the oopho- 
ron. 
2. Cysts of the corpus luteum. 
3.Multilocu- 
lar cysts. 
(a) Simple. 
(b) Glandular. 
(c) Dermoid. 
II. Cysts of the paroophoron: Papillary cysts of the ovary. 
III. Cysts of the paro- 
varium. 
1. Cysts of Kobelt's tubes. 
2. Cysts of the 
ver t i c a 1 
tubes. 
(a) Simple. 
(&) Papillary. 
Multilocular 
Cysts of 
the Ovary. 
Papillary Cysts 
of the Ovary. 
Cysts of the 
Vertical 
Tubes. 
1 Intraperitoneal. 
2. Pedunculated. 
3. Multilocular. 
4. Ovary destroyed. 
5. Tube normal. 
6. Unilateral. 
7. Specific g r avi t y 
of contents above 
1010. 
8. No papillary 
growths. 
1. Extraperi toneal. 
2. No pedicle. 
3. Unilocular. 
4. Ovary normal. 
5. Tube normal. 
6. Bilateral. 
7. Specific gravity 
of contents not 
diagnostic. 
8. Papillary 
growths. 
1. Extraperitoneal. 
2. No pedicle. 
3 Unilocular. 
4. Ovary normal. 
5. Tube elongated. 
6. Unilateral. 
7. Specific gravity 
of contents below 
1010. 
8. Rarely papillary 
growths. 
The symptoms of ovarian cysts are not at all 
diagnostic. There may be some menstrual dis- 
turbance, usually menorrhagia; pain may or may 
not be present. The pain of ovarian cysts is due to 
pressure, and is largely dependent upon the direc- 
tion of growth of the tumor. Cysts growing into 
the pelvis between the layers of the broad ligament 
usually cause the greatest disturbance. Most 
frequently, if the cyst is intraperitoneal, the pa- 
tient complains of no symptoms until the tumor 
has grown to sufficient size to distend the abdomen. 
Later she loses weight and strength, the general 
health fails, and her features assume a character- 
istic pinched expression, which has been called 
facies ovariana. 
The physical signs of ovarian cysts are usually 
more distinct. Inspection may reveal a localized 
or general enlargement of the abdomen. Palpa- 
tion will reveal a tense resisting tumor, usually 
smooth and regular in outline, which will give a 
distinct wave of fluctuation. Percussion shows dul- 
ness over the face of the tumor, with resonance 
above it and in the loins. The dulness does not 
change when the position of the patient is changed. 
Bimanual examination will reveal the uterus 
normal in size, and usually displaced by the weight 
of the tumor. The lower segment of the tumor can OXALURIA 
OZONE 
oxalic acid has been taken. The antidotes are the 
calcium carbonate or hydrate in such forms as 
lime-water, chalk, whiting or wall-plaster in 
water, or magnesia. Potassium and sodium 
carbonates and bicarbonates are to be avoided. 
Bland mucilaginous drinks should be given, and 
warm poultices should be applied to the abdomen. 
Cerium oxalate is official. See Cerium. 
OXALURIA.-A term used to indicate the 
presence of calcium oxalate in the urine in an undue 
amount. There is a white deposit on standing. 
It occurs in the urine of hypochondriac and de- 
pressed patients, and in that of gouty patients. Ex- 
cessive venery and masturbation will produce it, 
as will the ingestion of certain foods, as rhubarb. 
See Urine (Examination). 
OX-GALL.-See Fel Bovis. 
OXYGEN.-Oxygen is inhaled as a therapeutic 
agent in diseases of the respiratory organs and 
blood. It is essential to respiration, blood-forma- 
tion, nutrition and tissue change, in fact to life 
itself; its combination with the tissues yields heat 
and other energy. Combustion is also dependent 
upon it, consisting of a rapid oxidation, with the 
evolution of heat and light. It exists also in an 
allotropic form known as Ozone (q. v.). See 
also Hydrogen Dioxid. 
OXYTOCICS or ECBOLICS, agents which stimu- 
late the muscular fibers of the gravid uterus to 
contraction, and may therefore produce abortion. 
In small doses the same remedies are as a rule 
emmenagog (q. v.). Their mode of action has not 
been clearly made known, but it is generally be- 
lieved to be due in some cases to direct stimula- 
tion of the uterine center in the cord, in others 
to congestion of the uterus producing reflex 
stimulation. The principal are: Ergot, ustilago, 
savin, potassium permanganate, hydrastis, borax, 
cotton-root bark, oil of rue, pilocarpin, viscum 
flavescens, strong purgatives. 
Any drastic purgative, or gastrointestinal irri- 
tant, may produce abortion by reflex action. The 
volatile oils act in this manner, also colocynth and 
many other agents used by women to produce 
abortion, as tansy, pennyroyal, etc., all of which are 
dangerous to life in doses sufficient to excite the 
action of the gravid uterus. 
OXYURIS.-See Worms (Round-). 
OZENA.-A chronic inflammation, with subse- 
quent atrophy, of the mucous membrane of the 
nose, accompanied by the formation of dry crusts 
and by a very offensive odor. The great difficulty 
in dealing with ozena is the removal of the crusts 
and thickened secretions upon which the fetor 
depends. While the secretions remain, decom- 
position is present, and the diseased surface is 
never in condition for healing. The treatment, 
therefore, may be summed up in the words ab- 
solute cleanliness. The persistent use of the nasal 
douche should be continued until every trace of 
thickened secretion is removed. At first, or in 
neglected cases, hot fomentations and steam 
inhalations may assist in the removal. When the 
dried discharge adheres to the roof of the nasal 
cavity, a syringe may be used to wash it out, or 
it may be mopped out by pledgets of cotton-wool 
twisted around a probe. A solution of sodium 
bicarbonate may be used at first, and when crusts 
are removed, an antiseptic solution should be sub- 
stituted. Potassium permanganate, zinc chlorid, 
zinc sulphate, carbolic acid, solution of chlorinated 
soda, potassium chlorate, silver nitrate, sulphurous 
acid, powdered alum, boroglycerin, glycerite of 
tannin, tincture of iodin, boric acid, chloral hy- 
drate, and perchlorid of mercury may all be used 
locally in aqueous solution. 
Cotton tampons may be saturated with: 
Beta-naphthol or naphthol, gr. xij 
Tincture of quillaja, 3 jss 
Distilled water, enough for 3 j. 
The interior of the nose may be painted with 
balsam of Peru, and tampons, saturated with 
the same drug, may be left in contact with the 
deeper parts of the cavity. This effectually de- 
stroys all fetor. Powders of boric acid, bismuth, 
camphor, tannin, calomel, and iodoform have been 
used, but they are less satisfactory than liquid 
applications. As a rule, ulcers heal readily under 
constant irrigation by weak saline or antiseptic 
solutions. When diseased bone is present, it must 
be removed before healing can begin. Curettage 
is often very successful. Syphilitic ozena re- 
quires local treatment with mercuric chlorid in 
solution of 1:5000 to 1:10,000. Calomel may be 
insufflated with advantage. Constitutional treat- 
ment is of great importance in ozena, and is 
especially required in strumous and syphilitic 
cases. See Nose (Caries), Rhinitis (Chronic). 
OZONE.-An allotropic form of oxygen, its 
molecule having the structure O8. It is present 
in the atmosphere in small quantities, being 
produced constantly by the evaporation of water, 
by electric discharges, and in the growth of chloro- 
phyll-containing plants. It is also formed during 
the slow oxidation of phosphorus, turpentine, and 
other essential oils. In the sickroom it may be 
produced by dissolving in water a mixture of 
manganese dioxid, potassium permanganate and 
oxalic acid. It is an active oxidizing agent, 
possessing bleaching and antiseptic properties. 
It has been recommended in cases similar to those 
in which oxygen is used; also in infectious diseases, 
as diphtheria. See Oxygen. PACHYMENINGITIS 
PAIN 
p 
PACHYMENINGITIS.-See Meningitis. 
PACK.-A blanket wrapped about the body. 
A cold pack is a blanket wrapped about the body 
after having been wrung out of cold water. A 
half pack is one limited to the trunk. A hot pack 
is a blanket wrung out of hot water and wrapped 
around the body. A wet pack is a blanket wrung 
out of warm or cold water, and wrapped about the 
body or a part, and surrounded by dry blankets. 
It may be used as a means of reducing'temperature 
(cold pack), or to produce sweating (hot pack). 
PAGET'S DISEASE.-See Breast (Diseases); 
Ostitis Deformans. 
PAIN.-Bodily or mental suffering. Distressing 
or agonizing sensation. It is usually due to irrita- 
tion of sensory nerves, although there are said to 
be pains of central origin. 
The qualifying terms applied to pain are: P., 
Boring, severe pain in bones of a boring character. 
P., Electric. See Pain (Fulgurant). P., Fulgu- 
rant, P., Fulgurating, the intense shooting, cutting 
pains affecting principally the limbs of patients 
suffering from locomotor ataxia. P., Girdle, a 
painful sensation as of a cord tied about the waist; 
it is a symptom of organic spinal-cord disease. 
P., Growing, a popular term for the soreness about 
the joints in young persons at puberty. Some 
attribute these pains to increased vascularity of the 
epiphyses of long bones; others believe them to be 
rheumatic. P., Jumping, the pain peculiar to 
disease of joints when the bone is exposed by ulcer- 
ation of the cartilage. P., Lancinating. See Pain 
(Fulgurant). P., Lightning. See Pain (Fulgur- 
ant). P., Osteocopic, bone-tiring pains; a symp- 
tom of ostitis, periostitis, and secondary syphilis. 
P., Shooting. See Pain (Fulgurant). P., Starting. 
Synonym of Pain (Jumping). 
General Diagnosis.-As an aid to diagnosis, the 
kind of pain and its location are often of higher 
value than any other symptoms. Thomson 
divides pain into 6 different forms: (1) That due 
to inflammation; (2) that due to pressure; (3) that 
due to stretching; (4) neuralgic pain; (5) subjec- 
tive pain; (6) cutaneous reflex pain. 
An investigation should begin with a request that 
the patient describe just where the pain is felt most, 
and where it first began. While he is doing so, the 
gestures which he uses should be carefully noted. 
When the pain is due to inflammation, if exter- 
nal, as in a joint, the patient will avoid pressure 
upon the most painful part. If deeper seated, the 
gestures are often expressive of the varying kinds 
and distribution of the pain, according to the tex- 
ture inflamed. Thus, the diffused soreness of a 
mucous-membrane inflammation causes the ges- 
ture of bronchitis to be made with the whole hand 
laid on the sternum, and then passed over and 
across the chest. A similar movement of the hand 
across the abdomen never implies peritonitis, but 
catarrhal intestinal inflammation. With pleurisy 
and peritonitis, on the other hand, the tips of the 
straightened fingers are used to indicate the stab- 
bing nature of the pain. In the localized pain of 
commencing appendicitis the open hand is used, 
as with an inflamed joint. In pleurodynia the 
whole hand is pressed firmly to the side to prevent 
movement of the ribs. In rheumatic fever the 
pointing by the patient to the epigastrium or to the 
xiphoid cartilage, especially if followed by a move- 
ment from the precordium up the neck or into the 
left arm, is significant of cardiac inflammation. 
So also the gesture in gastritis, whether acute or 
chronic, is wholly different from that in colic. 
Inflammatory pains about the head may have very 
characteristic gestures^ The use of one finger-tip 
to localize it on the scalp is strongly significant of 
intracranial syphilis. The finger-tips passing up 
the side of the face and stopping on the scalp an 
inch below the sagittal suture indicates pain ascend- 
ing from a tooth, and should not be mistaken for 
trigeminal neuralgia. In conjunctivitis the hand 
is laid over the eye. In iritis the finger is pointed 
toward it, not touching it, and then passed up the 
forehead to the inner side of the nose or to the 
malar process. In glaucoma the gesture may be 
reversed, as if the pain were emerging from the 
orbit. All these gestures differ entirely from 
those of head pains not inflammatory. Menin- 
gitis, whether cerebral or spinal, is significantly 
indicated by absence or suppression of gesture, 
for reasons to be noted further on. There are 
exceptions to this in some cases of tubercular 
meningitis. But the gesture of myelitis, with both 
hands passed from the back across the abdomen to 
describe the cord- oqband-like sense of constriction, 
is almost pathognomonic. 
On the other hand, the gestures indicating the 
seat of greatest pain produced by pressure, as by 
tumors, abscesses, etc., or cramps, markedly con- 
trast with those of inflammatory pains in showing 
no apprehension in touching or in moving the part. 
Here the locality indicated at first by the gesture is 
of importance to note, and whether, on repeating 
the question, the same place is again started from, 
because the patient's hand then moves in a fashion 
expressive of the extension or radiation of the pain 
from the original focus, although he may describe 
the pain as equally present at some distance from 
the spot first pointed out. Hence his unconscious 
repetition of the sign with which he commenced is 
of much significance. Thus, a patient with a 
growth springing from the lumbar vertebrae al- 
ways first pressed the point of two fingers deeply 
into the abdomen below the umbilicus, while the 
fingers of the other hand moved over the sacrum, 
where he insisted his pain was chiefly. A fixed 
pain in the back caused by an aneurysm is often 
indicated by the extended thumb, and likewise the PAIN 
PAIN 
pain preceding herpes zoster, . but no spinal in- 
flammatory pain will elicit such a gesture, nor will 
the pains of so-called spinal irritation. In stretch- 
ing pains, such as in biliary or renal colic, or cramps, 
as in lead colic, the contrast to inflammatory 
pains is shown by the forcible grasp or pressure 
which the patient makes on the abdomen, while 
the characteristic radiations of the different varie- 
ties may be very plainly represented. Even when 
the pain has ceased, the gestures descriptive of 
what he has experienced may be equally conclusive 
as to their nature (Thomson). 
Inflammatory pains have three great characteris- 
tics. The first is that pain is elicited by pressure 
upon, or by handling, the inflamed part; and the 
rule is that pressure produces the maximum 
amount of pain at the site of the inflammation. 
This fact-is useful in diagnosis, both positively and 
negatively. Thus, an inflammatory pain in the 
leg may be due to peripheral neuritis, to sciatica, 
to hip-joint disease, to gouty arthritis, to rheu- 
matic arthritis, to muscular rheumatism, or to 
spinal meningitis, and each one of these may be 
distinguished from the others by appropriate 
palpation. In peripheral neuritis pain is most 
complained of on pressure upon the skin and super- 
ficial structures much more than when one lifts the 
whole limb in the hands or moves its joints. 
Sciatica is diagnosed by the special tenderness on 
pressure at the sciatic notch, along the course of 
the nerve down the back of the thigh, or deep in 
the popliteal space, or between the heads of the 
soleus in the calf; hip-joint disease by pressing the 
head of the bone against the acetabulum. 
The second great characteristic of inflammatory 
pain is that it is increased by any form of movement 
of the inflamed part, not excepting its own proper 
functional movements. The inflamed part, there- 
fore, is both voluntarily and involuntarily kept at 
rest as much as possible. This is done by muscu- 
lar action, the afferent impression of this pain being 
reflected to all the associated muscles of the part 
to restrain their action, and even to muscles which, 
though not usually connected with the function of 
the part inflamed, may yet disturb it by their 
movements. Examples of the first kind are seen 
in the fixity of joints by the contraction of their 
muscles whenever and as long as the joints are in- 
flamed, while the latter is shown by both the local 
or general rigidity of the abdominal muscles, accord- 
ing to the local or general state of inflammation 
underneath. Thus, comparative palpation made 
by both hands in the iliac fossae is of help in the 
early diagnosis of typhoid fever. In appendicitis, 
from the commencement of the irritation, the 
muscular resistance over the cecum may give the 
impression of a solid tumor much before there has 
been time for exudation or pus-formation. 
The third great characteristic of inflammatory 
pain is that it is accompanied by disturbance of 
the normal function of the injured part. This does 
not happen with the other varieties of pain-at 
least, as a characteristic of them. Neuralgic 
headache, for example, is not accompanied by de- 
lirium, or, ordinarily, by intolerance of light or of 
sound, as the headache of meningitis is. Neural- 
gic pains in the spine, in the arms, or in the legs do 
not produce stiffness nor fetter the movements of 
those parts whose chief functions are to execute 
movements, as do inflammatory pains. So the 
diagnosis between pleurisy and pleurodynia lies in 
the fact that the pain on movement of the ribs in 
pleurisy causes the functional symptom of cough, 
while that of pleurodynia does not, for the seat of 
the pain is not in the pleura at all. 
Besides these three great characteristics of in- 
flammatory pains, the sensation itself often varies 
in kind, according to the tissue involved. The 
rule is, the softer the texture, the more acute the 
pain; so that it may be described as only dull and 
heavy, as in inflammation of the liver or in pneu- 
monia which has not involved the pleura. In 
inflammations of mucous membranes the pain, if 
moderate in degree, is more like a diffused soreness; 
if severe, it may be termed burning. Whenever 
griping or bearing-down sensations develop, it is 
because the inflammatory irritation has extended 
from the mucous membrane to the muscular coat 
of the wall of the canal or viscus which the mem- 
brane lines. Pain of inflamed serous membranes 
is much more acute than in the case of mucous 
membranes, and is likely to be lancinating or stab- 
bing, as is indicated by the patient's gesture. 
Pain of inflamed fibrous tissues, such as muscu- 
lar fascia, nerve-sheaths, periosteum, dura, etc., 
if moderate, is of a dull, aching character; but if 
severe, is very violent on account of the unyield- 
ing nature of the tissue. A serviceable indication 
of the seat of the inflammatory process is afforded 
by the susceptibility of patients with any form of 
fibrous-tissue inflammation to changes in the 
weather. In health there is a perfect adjustment 
between the centrifugal pressure of the circulation 
and the centripetal pressure of the weight of the 
atmosphere. Changes in the latter, as indicated 
by the fall in the barometer on the approach of a 
storm, are promptly compensated for by the nerve- 
fibrils being readily removed in the softer tissues 
from unbalanced intravascular pressure, but not so 
in the denser fibrous tissues. Hence the good, but 
inconvenient, barometers which a gouty man has in 
his toes, that may ache worse while the sky is yet 
clear, but which he knows, from experience, means 
that the clouds are on their way. It is well, there- 
fore, to ask whether a headache complained of 
grows worse just before a storm, when you have 
reason to suspect that it is no mere functional 
trouble, but a cephalalgia of syphilitic origin 
(Thomson). 
Referred Pains.-These are made clear by the 
illustrations, the following sections, and the table 
at the end of the article. 
Local Significance.-Pain in the head, when con- 
tinuous, dull, aching, and increased on lowering the 
head, may be due to rheumatism. When of like 
character and limited to the forehead, it may be 
dependent on gastric derangement or eye-strain. 
It is likely to be neuralgic when limited to one spot 
of the head or face, and darting from spot to spot 
and sharp and paroxysmal. When accompanied 
by nausea, vomiting, and giddiness, it is called mi- 
graine, but is probably due to eye-strain. Cerebral PAIN 
PAIN 
disturbance may be productive of like pains, but 
in this case they are continued for more than a day 
or two. The ophthalmoscope may help to differen- 
tiate here between migraine and cerebral trouble 
or .Bright's disease. Tumor, aneurysm, abscess, 
hemorrhage, or meningitis are forms of intracra- 
nial disease accompanied by pain in the head, 
vomiting, giddiness, squint, or some other evidence 
of localized paralysis of a cranial nerve. A more 
or less variable amount of pain in the head will 
remain after recovery from hemiplegia. The pain 
in the head from Bright's disease is likely to attack 
the back of the head. The pain in the head from 
glycosuria is more or less continuous, with violent 
exacerbations. Generally 
speaking, persistent pain in the 
head, in one unaccustomed to 
it, should call for the use of the 
ophthalmoscope and urine an- 
alysis, particularly in females. 
Lead-poisoning may also be re- 
sponsible for headaches. When 
chlorosis exists, the pain in the 
head is fixed in one spot, and is 
piercing. The pain of hysteria 
often simulates it. Pains in the 
head are often due to ocular dis- 
turbance other than abnormali- 
ties of refraction: as, for in- 
stance, weaknesses or imbalance 
of certain eye-muscles. The 
pains in the head in locomotor 
ataxia are of a darting, shoot- 
ing character. See Headache. 
Pain in the neck may be due to 
rheumatism, which generally 
affects the large muscles; to uric 
acid excess, or some equivalent, 
which excites a subacute inflam- 
mation of severe type; to neu- 
ralgia; to caries of the spine; to 
rheumatoid arthritis of the cer- 
vical vertebrae; or to herpes 
zoster. 
Pain in the chest may be re- 
ferred to the chest-wall or to 
the interior of the cavities. 
When due to muscular rheumat- 
ism, syphilitic periostitis, inter- 
costal neuralgia, or to the en- 
croachment of aneurysm or 
tumor, the pain is probably su- 
perficial. The first cause would probably be indica- 
ted by an absence of febrile action and the depen- 
dence of the pain upon movement. Syphilitic per- 
iostitis would be distinguished by thefingeroutlining 
a node upon the clavicle, sternum, or ribs, and by the 
history or other symptoms. The character of the 
pain would indicate an intercostal neuralgia, 
especially when coupled with the history of pre- 
vious neuralgic attacks in other portions of the 
body. 
Physical examination will detect or exclude 
aneurysmal tumor. Pleurisy causes particularly 
well marked pain on coughing. It may be con- 
founded with intercostal neuralgia or muscular 
rheumatism. Continued deep and dull pain in the 
chest points to intrathoracic growth, aneurysm, 
or abscess. See Chest. 
Pain about the heart may be caused by begin- 
ning'pericarditis or endocarditis. Purely nervous 
debility is often attended by a dull and more or 
less constant pain about the heart, and cardiac 
palpitation and hysteria are often accompanied 
by a somewhat sharp pain just under the mamma. 
The pain of angina pectoris is not confined to the 
heart, but extends to the left arm and various parts 
of the chest. Pains in the chest also accompany 
the various diseases of the lungs and pulmonary 
tubes. See Heart (Pain). 
FRONTO-NASAL AREA. Af- 
fected by disease of cornea, 
anterior chamber of eye, up- 
per part of nose and upper 
incisor teeth; sometimes by 
disease of lungs. \ 
ORBITAL AREA. Affected by 
strain of ciliary muscle (es- 
pecially in hypermetropia) and 
disease of the ciliary body; 
sometimes by disease of heart, 
aorta or lungs. 
FRONTO-TEMPORAL AREA. 
Affected by iritis and glauco- 
ma; sometimes by disease of 
lungs, aorta or cardiac end of 
stomach. \ 
TEMPORAL AREA. Affected 
by glaucoma; sometimes by 
disease of lungs, cardiac end 
[of stomach or liver. Especially 
i associated with nausea and 
' vomiting. 
MAXILLARY AREA. Affected 
by iritis, increased tension of 
vitreous humor and disease of 
2d upper bicuspid tooth or 
adjacent part of hard palate?Z 
MANDIBULAR AREA. * Af- 
fected by disease of 2d and 
3d upper molar teeth. 
MENTAL AREA. Affected by 
disease of anterior part of 
tongue and lower incisor, ca- 
nine and 1st bicuspid teeth. 
NASO-LABIAL AREA. Af- 
fected by disease of respira- 
tory portion of nose and upper 
canine and 1st bicuspid teeth. 
INFERIOR LARYNGEAL 
AREA. Affected by disease 
of vocal cords and lower part' 
of larynx. 
SUPERIOR LARYNGEAL 
"* AREA. Affected by disease 
Of upper part of larynx, pos- 
terior part of tongue and 3d 
lower molar tooth. 
Areas of Referred Pain.-{From Head.} 
Pain in the spinal column is commonly indicative 
of a state of nervous exhaustion, rather than of dis- 
ease of the spinal cord. Diseases of the cord do 
not usually give rise to such pain, unless attended 
by disease of the spinal vertebrae. Spinal menin- 
gitis gives pain only on movement. Myelitis is 
attended by an encircling pain-as of a band in 
the wall of the chest or abdomen-and when 
accompanied by a "bloated feeling," is a serious 
symptom. Aneurysm and malignant growth 
resemble this condition, but the pain in the two 
last instances is often constant and excessive, with 
a good deal of tenderness of the surface of the 
spine. A "stinging" pain of the chest is often PAIN 
PAIN 
complained of in beginning caries of the vertebrae. 
Heavy pressure on the spine will cause a like pain, 
and the acts of stooping, or of lifting weights, or of 
jumping to the ground will cause complaint of pain 
in the spinal column in this disease. See Loco- 
motor Ataxia, Spinal Cord. 
Pain in the abdomen may be in the wall or cavity. 
Inflammation, abscess, neuralgia, herpes, over- 
strain, or fatigue may be responsible for pain in the 
wall. Pain in the cavity of the abdomen may be 
dependent on internal strangulation of the bowel, 
strangulated hernia, peritonitis, the false pains of 
labor, enteritis, appendicitis, tympanites, fecal 
tion of the connective tissue between the muscles. 
When the pain in the back is stabbing, paroxysmal, 
or independent of muscular movement, it is prob- 
ably neuralgic in character. Contrary to the popu- 
lar idea, chronic nephritis is not usually associated 
with pain over the kidneys. 
Pain in the extremities may be due to neuralgia. 
When paroxysmal in character-sudden, sharp, 
lightning-like, darting through one or more limbs 
and severe enough to make one cry out-the pains 
are probably due to the early stage of locomotor 
ataxia. They will occur in paroxysms, lasting 
hours, days, or weeks, and subside as quickly as 
they came. Rheumatic pains, 
gnawing and aching pains oc- 
cupying the joints in acute in- 
flammations, also affect the ex- 
tremities. 
The treatment of pain is always 
primarily directed to its causa- 
tion. As a rule, pain should 
be relieved temporarily, since 
its continuance is exhausting 
and mischievous to the nervous 
system. However, w'hen it 
constitutes a vital point in diag- 
nosis, the administration of 
narcotics is ill-advised. Rest is 
essential, while local applica- 
tions, as counterirritants, poul- 
tices, sinapisms, or anodyne 
liniments are most ready means 
in many cases. Superficial pain 
is often relieved by a plaster or 
extemporaneous liniments con- 
taining laudanum or some other 
fluid preparation. The oleate 
of morphin alone is said to be 
penetrating, but it is doubtful 
whether such applications are 
of direct value. Intense pain, 
as from the passage of a cal- 
culus, is best treated by the 
hypodermic injection of mor- 
phin sulphate (1/4 to 1/2 grain) 
with atropin sulphate (1/100 
grain), while the preparations 
of opium may be given by the 
mouth for the same purposes. 
Severe pain enables the system 
to resist the action of opium. 
Opium is the most efficient and 
universally used drug for relieving pain, and mor- 
phin is its most analgesic alkaloid. A single in- 
jection is sometimes curative in sciatica and other 
neuralgias. In combination with antipyrin it is 
more efficient than when used alone. Codein is 
another opium derivative, having special action 
over abdominal and ovarian pain, and is not liable 
to give rise to the drug-habit. 
The treatment of inflammatory pains is that of 
the inflammation itself, and, hence, often different 
from, if not the reverse of, the treatment of other 
kinds of pain. The first indication is rest, includ- 
ing the position which assures most complete rest 
VERTICAL AREA Affected 
toy disease of posterior part of 
•ye, increased tension of mid* 
die ear and disease of stom- 
ach or liver. 
FRONTO-TEMPORAL AREA. 
Affected by iritis and glauco* 
ma; sometimes by disease of 
lungs, aorta or cardiac end of 
stomach. 
FRONTO-NASAL AREA. Af 
fected by disease of cornea 
/anterior chamber of eye, up 
per part of noee and uppe 
incisor teeth) sometimes b 
disease of lunge. 
OCCIPITAL AREA. Affected 
by disease of posterior part ol 
dorsum of tongue, kidney, ure- 
ter, ovary, testicle and pros- 
tate gland. 
J MAXILLARY AREA. Affected 
f by iritis, increased tension of 
vitreous humor and disease of 
I 2d upper bicuspid tooth or 
adjacent part of hard palate. 
HYOID AREA. Affected by 
disease of middle ear or drum 
membrane, tonsil, middle por- 
tion of tongue, and 1st and 2d 
tower molar teeth. 
MENTAL AREA. Affected by 
disease of anterior part of 
tongue end lower incisor, oa* 
nine and 1st bicuspid teeth. 
'Inferior laryngeal 
AREA. Affected by disease 
of vocal cords and lower part 
of larynx. 
Areas of Referred Pain.-(From Head.') 
accumulations, colic, biliary or renal calculi, and 
on hysteria. See Abdomen (Pain). 
Pain in the loins and back may arise from conges- 
tion of the kidneys or nephritis, renal calculus, 
abscess or morbid growth, flatulent distention of 
the bowels or retained feces, tumor of the bowel, 
abscess of the rectum, an undiscovered hernia, 
flexions and morbid growths of the uterus, ulcera- 
tions of the cervix, the approach of the catamenial 
period, retention and overdistention of the bladder 
(which also gives pain in the hypogastric region), 
or to Lumbago (q. v.). Lumbago depends upon 
rheumatism of the muscles, or subacute inflamma- PAIN 
PAIN 
After rheumatic carditis the patient had better 
stay in bed 3 or 4 months if he still has cardiac 
pains and a quickened pulse. Nothing is more 
serviceable sometimes in the later stages of pleurisy 
than to limit, as much as possible, the movements 
of the ribs by firmly strapping the whole affected 
side of the chest. But the instances in which this 
principle can be applied are too numerous to men- 
tion here. In many acute inflammations the vas- 
cular sedative action of topical blood-letting is 
often remarkably effective in relieving the pain. 
On the other hand, with the pains of chronic 
inflammations the stimulant effect of counter- 
irritation is preferable, according to the rule that 
the indications in the treatment 
of chronic inflammations are 
the opposite of those for acute 
inflammations. In traumatic 
lesions both the pain and the 
inflammation are generally 
treated best by local applica- 
tion of ice-bags, but cold is 
useless when the inflammation 
is due to a general cause in the 
blood, as in rheumatic and 
gouty arthritis. Cold applica- 
tions should be discontinued 
at once if they cause a neu- 
ralgic pain to take the place of 
an inflammatory pain. Many 
internal inflammatory pains are 
best relieved by the sedative 
properties of moist heat applied 
to the surface, as by poultices, 
etc., according to the general 
law that the cutaneous sensory 
nerves are always in association 
with the vascular nerves of the 
parts underneath. The best 
drug for inflammatory pain is 
opium. Next comes aconite, 
especially in serous membrane 
and cardiac inflammations. 
The coal-tar analgesics, so valu- 
able in the other kinds of pain, 
are comparatively useless in in- 
flammatory pains. 
The following list, taken 
from Potter's " Therapeutics, 
Materia Medica and Pharmacy," 
contains the agents most em- 
ployed in the treatment of 
pain: Opium is the most effi- 
cient of all analgesics and is 
universally used to relieve pain 
from any cause except acute inflammation of 
the brain; opiates soon lose their power in 
any particular dose, and require increasing 
dosage to sustain their analgesic influence, 
hence in chronic cases all other means should 
be exhausted before resorting to them. Mor- 
phin is the most analgesic alkaloid of opium; 
hypodermically in the vicinity of the nerve it is 
efficient when not so by the stomach; the mor- 
phin-habit must be kept in mind; a single 
injection thereof is sometimes curative in sciatica 
and other neuralgias; the conjoined administration 
of morphin and antipyrin is much more efficient 
in pain than the use of either agent alone. Codein 
has a special influence over abdominal pain and 
that of the ovaries, and is not liable to give rise to a 
drug habit. Dionin in 4 to 7 percent solution 
locally is the best analgesic for the eye. Bella- 
donna is the best remedy for every kind of pain in 
the pelvic viscera. Atropin, hypodermically in 
local pain, neuralgia, sciatica, glaucoma; when it 
succeeds, has more lasting effect than morphin; 
for sciatica, tic douloureux; has little value unless 
the pain be due to spasm or some cause situated 
so that the remedy can be brought into direct con- 
OWfTAL AREA. Affected by 
strain of ciliary muscle 'es- 
pecially in hypermetropiat and 
disease of the ciliary body; 
sometimes by disease of heart, 
aorta or tungs. 
PARIETAL AREA. Affected 
by disease of middle ear and 
pyloric end of stomach. 
TEMPORAL AREA. Affected 
glaucoma; sometimes by dis- 
ease of lungs, cardiao end of 
stomach or liver. 
NASO-LABIAL AREA. Af- 
fected by disease of respira- 
tory portion of nose and upper 
canine and 1st bicuspid teeth. 
MANDIBULAR AREA. Af- 
fected by disease of 2d and 
3d upper molar teeth. 
SUPERIOR LARYNGEAL 
AREA. Affected by disease 
of upper part of larynx, pos- 
terior part of tongue and 3d 
lower molar tooth. 
Areas of Referred Pain.-(From Head.) 
tact with sensory nerve-endings. Duboisin may 
be used instead of atropin. Cocain, as a local 
anesthetic to mucous surfaces, or hypodermically 
for minor operations involving a small area, as 
circumcision, eye operations, has no equal; a 4 
percent solution is generally employed; also as a 
general anesthetic by spinal subarachnoid injec- 
tion. Eucain is fully as efficient as cocain and 
much less toxic; in medicinal doses is harmless and 
does not affect the heart. Antipyrin is a most 
efficient analgesic in doses of 10 to 15 grains, being PAIN 
PAIN 
especially adapted to neuralgia, migraine and the 
pains of gouty and rheumatic origin, but is of no 
value in pain due to a local inflammation; it may be 
used hypodermically. Acetanilid is highly effi- 
cient in doses of 4 to 7 grains for the pains of loco- 
Phenocoll hydrochlorid, in doses of 12 to 15 grains, 
is a good analgesic in the neuralgic pains of influ- 
enza, and in gouty and rheumatic pain. Lacto- 
phenin is analgesic and nontoxic; a feeling of 
comfort follows its use. Chloroform by inhal- 
Diagram of Skin Areas Corresponding to Different Spinal Segments.-(From Tyson, Starr and Head.) 
motor ataxia and those of rheumatic origin, also 
locally as a dry dressing for painful wounds, ulcers, 
etc.; it is the active ingredient in a host of recent 
proprietary remedies against pain. Acetpheneti- 
din, efficient in 10-grain doses, for neuralgia, hemi- 
crania; is largely used for the relief of pains of the 
character for which antipyrin is employed. 
ation as a general anesthetic; internally for the pain 
of colic, even that of lead colic, and externally as 
liniment with other substances for chronic neural- 
gic or rheumatic pains; the vapor to the raw sur- 
face of cancers, to the photophobic eye, etc. 
Ether as spray for local anesthesia, by inhalation 
for general anesthesia; anesthetics should be PAIN 
PALATE, DISEASES 
employed only when pain is exceedingly severe 
and transient. Hydrated chloral is analgesic only 
in large and dangerous doses; sometimes relieves 
neuralgia, chronic rheumatic pains, colic, gastral- 
gia, etc. Aconite was formerly much used for 
neuralgic pain; aconitin locally is one of the most 
certain and powerful palliatives in neuralgic, 
rheumatic and gouty pains; especially in trigemi- 
nal neuralgia. Veratrin as ointment locally for 
neuralgia, is readily absorbed through the skin 
and is more dangerous than useful. Guaiacol, 
locally or by hypodermic injection, 1 part in 10 of 
olive oil, or mixed with equal part of glycerin for 
painting on the surface, is an efficient local anes- 
thetic, and is used successfully in orchitis, in neu- 
ralgic pains of tuberculous subjects, also in sciatica 
and rheumatism; a few drops rubbed in gently 
give immediate relief in many superficial pains, 
also in labor-pains. Phenol pure, is a local anes- 
thetic, but has been supplanted by cocain. Creo- 
sote locally is efficient for the pain of an exposed 
dental nerve. Ichthyol locally is analgesic against 
inflammatory pain; hypodermically is analgesic, 
less so than morphin and less dangerous. Amyl 
nitrite, also nitroglycerin and other nitrites, are 
effective usually against cardiac pain; especially 
when arterial spasm exists as in angina pectoris. 
Cannabis indica is inferior to opium, but may be 
tried w'hen the latter is contraindicated for any 
reason. Salicylates are efficient in rheumatic and 
gouty pain, also in rheumatic neuritis. Mesotan 
locally for superficial rheumatic pain. Iodoform 
in suppository for painful disease of the rectum or 
bladder; as a local analgesic in painful ulcers, 
hemorrhoids, anal fissures, etc. lodids are magical 
for syphilitic nocturnal pains of the head; ammon- 
ium iodid (3 grains in 1 ounce of olive oil), with 
friction causes the disappearance of nocturnal 
syphilitic pains. Cimicifuga relieves many kinds of 
pain, as neuralgia of fifth cranial nerve, rheumatic 
headaches, ovarian neuralgia, dysmenorrhea; infer- 
ior to ergot in labor-pains or after-pains; 5 j doses 
of the tincture. Conium, in cancer, rheumatism, 
neuralgia, ovarian pain; also for the fulgurant pains 
of locomotor ataxia, chronic alcoholism, sciatica, 
phthisis, doses of x of a fluidextract of the 
unripe fruit every 1/2 hour, well watched. Iron, 
with belladonna, for the wandering pains of ane- 
mia, in which morphin is dangerous and bromids 
are useless. Oil of peppermint locally is some- 
times very effective in relieving pain; has been 
long used in China for neuralgia and subacute 
rheumatism. Menthol freely rubbed on for 
superficial neuralgic pain of peripheral origin. 
Rhatany relieves the pain of ulcers, burns, and 
blisters. Methylene-blue relieves neuralgic and 
rheumatic pains; has some analgesic action, but 
is uncertain, and has no advantage over the newer 
anilin derivatives. Electricity, the galvanic cur- 
rent for neuralgia; it is powerless against pain of 
phlegmonous inflammations; galvanism of the 
affected nerve gives certain relief; the positive pole 
on point of emergence, negative over superior 
ganglion of cervical sympathetic. Heat, if pain 
is without fever or inflammation, warm injections 
soothe the pain of cystitis, prostatitis and abdomi- 
nal pains generally. Hot water, as bath, relieves 
pain most wonderfully; cold, when pain is inflam- 
matory in origin. Phototherapy, the ultra-violet 
rays are very effective in relieving acute muscular 
pain, especially if obtained with iron-carbon 
electrodes. 
Organ Diseased. 
Spinal Segments 
whose Sensory 
Areas are Pain- 
ful. 
Cranial Areas in 
which Pain may 
also be Felt. 
Heart 
1, 2, 3 dorsal (an- 
gina pectoris). 
3, 4 cervical, 1, 2, 
3, 4, 5 dorsal. 
1, 2, 3, 4 dorsal... 
5, 6 dorsal 
6, 7 dorsal 
8, 9 dorsal 
7, 8, 9, 10 dorsal.. 
9, 10, 11, 12 dor- 
10, 11, 12 dorsal.. 
10, 11, 12 dorsal, 
5 lumbar, 1, 2, 3 
sacral. 
10 dorsal 
2, 3, 4 sacral 
11, 12 dorsal 
Orbital. 
Lungs 
Frontonasal, orbi- 
tal, frontotempo- 
ral, temporal. 
Orbital, frontotem- 
poral. 
F ron to temporal. 
Frontotemp., tem- 
poral. 
Vertical, parietal. 
Temporal, vertical, 
parietal,, occipital. 
Parietal occipital 
Ascending aorta... 
Arch of aorta 
Stomach, cardiac.. 
Stomach, pyloric.. 
Liver and appen- 
dages. 
Intestine 
Kidney and ureter. 
Prostate 
Occipital. 
Occipital. 
Occipital. 
Ovary or testicle.. 
Rectum 
Fpididvmis 
Oviduct 
11, 12 dorsal, 1 
lumbar. 
1, 2, 3, 4 sacral 
11, 12 dorsal, 1 
lumbar. 
10, 11, 12 dorsal, 
1 lumbar. 
1, 2, 3, 4 sacral (5 
lumbar very rare- 
ly). 
Bladder, mucous 
membrane and 
neck. 
Bladder, over-dis- 
tention and in- 
effectual contrac- 
tion. 
Uterus, in con- 
traction. 
Uterus, os 
PALATE, DISEASES.-The affections of the pal- 
ate are mostly surgical. The diseases of the palate 
are: (1) Congenital malformations; (2) inflamma- 
tion; (3) ulcers; (4) necrosis; and (5) tumors. 
Congenital malformations (see Cleft Palate) 
may be simple or phlegmonous, of the soft parts, 
or involve the hard palate, affecting the perios- 
teum and bone. 
Ulcers.-The principal forms of ulceration are 
those of syphilitic, tuberculous, or epitheliomat- 
ous origin. Injury gives rise to simple ulcers, 
which present no special feature of interest. 
Syphilitic ulcers are common, in the early second- 
ary stages of the disease being superficial, while deep 
ulcers occur in the tertiary stage and appear late- 
5 to 8 years after the primary lesion. They are 
generally single, have the usual characters, and 
may spread to the base of the cranium. Tubercu- 
lar ulcers, most usual in childhood, are associated 
with tubercular disease elsewhere. Small tuber- 
cles, projecting slightly above the surface, first 
appear, break down the erosions, coalesce into 
irregular ulcers of little depth, with festooned bor- 
ders and a yellowish base covered with pale granu- PALMAR ABSCESS 
PANCREAS, DISEASES 
iations. They may become serpiginous. Epithe- 
li omatous ulcers are rare. 
Tumors.-The glandular tumor is the most 
common. It is often found on the hard palate, is 
usually soft and elastic to the touch, painless, and 
causes no symptoms beyond the encroachment 
upon the buccal cavity. Erectile tumors are con- 
fined to the hard palate. Papilloma is infrequent 
and sarcoma is rare. Epithelioma rarely develops 
primarily in the soft palate. Cysts-mucous and 
dermoid-fibroma, enchondroma and osteoma, 
myxoma, lipoma and adenoma, and tumor growths 
of the palate, while inflammatory, and tubercular 
and gummatous swellings occur. 
Treatment of diseases of the palate must, as a 
rule, be directed to the particular disease affecting 
the palate in common with other adjacent struc- 
tures. Local antiseptic, astringent, and caustic 
treatment is of value. Surgical operations are 
often of the greatest service. 
PALMAR ABSCESS.-See Hand. 
PALPITATION.-Any spasmodic fluttering or 
tremor, especially the abnormally rapid beating, of 
the heart, of which the person is conscious. It is 
often associated with a choking sensation in the 
throat. It may be due to organic disease or to 
functional disturbance of the heart; very often it 
is caused by disorders of the stomach. See 
Heart-disease (Functional). 
PALSY.-See Paralysis. 
PANCREAS, DISEASES. Relations of Pancreas. 
-The pancreas is a compound racemose gland, con- 
sisting of a broad, slightly curved portion called 
the head, while the left extremity terminates in a 
pointed end denominated the tail, and the middle 
portion forms the body. The pancreas is from 
6 to 8 inches in length, extending transversely 
across the posterior wall of the abdomen, occupy- 
ing the epigastric and left hypochondriac regions. 
The head of the pancreas is in close relation with 
the duodenum and common bile-duct, the body 
being covered by the posterior wall of the stomach 
and the transverse colon, while the tail is placed 
over the left kidney and impinges upon the concave 
border of the spleen. 
Pancreatic Apoplexy.-Hemorrhage into the 
pancreas is generally the result of venous engorge- 
ment, traumatism, or atheromatous condition of 
the blood-vessels. The hemorrhage may be exces- 
sive, producing a rapid enlargement of the organ, 
with sudden pain, great tenderness, and a sense of 
fulness in the affected region, and accompanied by 
vomiting, paleness of the face, cold extremities, 
rapid and feeble pulse, and evident symptoms of 
sudden collapse. Death usually occurs within 
from 3 to 7 days. 
Acute Pancreatitis.-Acute inflammation of the 
pancreas. 
Etiology.-Septic infection through the medium 
of the pancreatic ducts, caused by such organisms 
as the colon bacillus, pyogenic cocci, typhoid 
bacillus, etc. See Colon Bacillus Infection. 
Pathology.-The pancreas is enlarged from 
excessive amount of blood in the part, and the 
infiltration of the tissues with red blood-cells and 
leukocytes. In some cases the process is a rapid 
one, leading to fatty degeneration, giving rise to 
abscess (suppurative pancreatitis) or gangrene 
(gangrenous pancreatitis). 
Symptoms and Clinical Course.-In acute 
inflammation of the pancreas the onset is marked 
by tenderness in the region of the pancreas, 
enlargement of the organ, slight fever, vomiting, 
and gastric distress. 
If the process is a suppurative one, or if gan- 
grene supervenes, all the symptoms become 
more pronounced, with sweat and chills, paleness 
of face, cold extremities, rise of temperature at 
first, then sudden decline, with evident symptoms 
of collapse. In the latter forms death usually 
occurs within 4 to 6 days. 
Prognosis is unfavorable. 
Treatment is the same as that for Peritonitis 
(?• v.). 
Chronic interstitial pancreatitis may be the 
result of cholelithiasis or biliary obstruction, or of 
the simple form of hemorrhagic pancreatitis. 
The resulting sclerosis then causes constriction of 
the common bile-duct and so gives rise to jaundice 
and a variable distention of the gall-bladder, 
accompanied by wasting and paroxysmal attacks 
of pain and ague-like seizures. The pulse may 
then be rapid, and so differs from the pulse in ordi- 
nary jaundice. If such symptoms arise in patients 
under forty, chronic interstitial pancreatitis may 
be suspected, since cancer of the head of the pan- 
creas is rare until after that age. A hard lump may 
be felt in the region of the head of the pancreas, and 
if there is also fat in the feces, sugar in the urine, 
and bronzing of the skin, a diagnosis may be arrived 
at. A special test for glycerin products of fat 
decomposition by Dr. Cammidge should give a 
positive reaction. The treatment is cholecysten- 
terostomy together with the removal of any gall- 
stones met with. The result may be a good and 
lasting recovery. Some cases of pancreatic dia- 
betes appear to have been secondary to this form 
of chronic pancreatitis, and the possibility of ward- 
ing off diabetes is a further recommendation for 
cholecystenterostomy. 
The Cammidge reaction in the diagnosis of pan- 
creatic disease, while it is not pathognomonic, is 
believed by many authorities to be highly sugges- 
tive. 
Technic of the Improved Method.-A 24 hour 
specimen of urine must be freed from albumin and 
sugar. To 40 c.c. of filtered acid urine are added 
2 c.c. of concentrated hydrochloric acid and the 
mixture is boiled 10 minutes, cooled and to it added 
water up to 40 c.c., then also 8 grams of lead car- 
bonate and it is then cooled again. After filtering 
the filtrate is treated with 8 grams of tribasic lead 
acetate to remove the glycosuric acid. The pre- 
cipitate is removed by filtering and to the filtrate 
is added 4 grams of powdered sodium sulphate, 
the mixture heated to the boiling-point, then 
cooled and carefully filtered. To 10 c.c. of the 
filtrate made up in a flask to 17 c.c. with distilled 
water, are added 0.8 gram of phenyl hydrazin 
hydrochlorid, 2 grams of sodium acetate and 1 c.c. 
of 50 percent acetic acid and the mixture boiled 
10 minutes. While hot it is filtered and the fil- PANCREATIC EXTRACT 
PAPER 
trate made up to 15 c.c. with hot water and 
allowed to stand. In several hours a yellow pre- 
cipitate forms which is observed under the micro- 
scope to consist of yellow crystals arranged in 
sheaves and rosettes. 
Carcinoma of the Pancreas.-The disease is 
usually primary and of the scirrhous variety. The 
seat is usually at the head of the organ. It may 
be secondary to carcinoma elsewhere, as in the 
stomach or intestines. 
Pathology.-The carcinomatous infiltration in- 
vades the tissues of the organ; there is great mul- 
tiplication of cells, which become packed together 
and form dense nodules. If the process continues, 
the common bile-duct becomes occluded from the 
pressure, and jaundice follows. Metastasis may 
occur, and the process extend to the duodenum, 
liver, stomach, or peritoneum. 
Symptoms and Clinical Course.-Jaundice, ten- 
derness in the epigastric region, and the presence 
of a nodular immovable tumor are the three most 
common symptoms. Together with these symp- 
toms there are fever, emaciation, fatty or greasy 
stools, and often glucose in the urine. 
Diagnosis.-From cancer of the stomach it may 
be distinguished by the fact that if the stomach is 
involved, the tumor is more superficial, is movable, 
and there is hematemesis and absence of free 
hydrochloric acid in the gastric contents one hour 
after a test-breakfast. In aneurysm of the aorta 
the tumor is not lifted up and down with each pul- 
sation, as in cancer of pancreas, and in the former 
there is a thrill on palpation, a bruit sound on 
auscultation, and jaundice is absent. 
Prognosis.-The disease is always fatal. 
Treatment is merely palliative. The diet may 
be the same as that used in cancer and ulcer of the 
stomach. 
Cysts of the Pancreas.-These are usually reten- 
tion cysts, the result of impaction of calculi in the 
pancreatic ducts. These cysts may attain con- 
siderable size. 
Symptoms and Clinical Course.-There is a 
slightly movable tumor in the left side of the epi- 
gastric region, containing a brownish or chocolate- 
colored fluid. Occasional attacks of colic and fatty 
stools may help distinguish the disease, although a 
diagnosis is often impossible. 
Treatment is purely surgical. 
PANCREATIC EXTRACT.-The pancreas, both 
in substance and extract, has been administered as 
a remedy for diabetes, but the results have been 
negative. A few instances are recorded in which 
its use was followed by some temporary ameliora- 
tion of the symptoms of the disease. See Organo- 
therapy. 
PANCREATIN.-A mixture of the enzymes 
naturally existing in the pancreas of warm-blooded 
animals, usually obtained from the fresh pancreas 
of the hog, or the ox, and consisting principally of 
amylopsin, trypsin, and steapsin; and proved to 
be capable of converting not less than 25 times its 
own weight of starch into substances soluble in 
water. Dose, 3 to 15 grains. 
Pancreatin digests albuminoids and converts 
starch into sugar and proteids into peptones, also 
emulsifies fats in the presence of an alkaline solu- 
tion. Prolonged contact with mineral acids ren- 
ders it inert. It is digested by pepsin, and hence 
probably never passes into the duodenum in its 
own character. Pancreatin is used to partially 
digest (peptonize) milk, gruel, soups, and other 
foods, before their administration in cases of great 
digestive debility. These peptonized foods may 
be administered by the stomach or the rectum, 
and are valuable in intestinal dyspepsia, wasting 
diseases, and convalescence from acute affections. 
See also Organotherapy. 
PANNUS.-Vascularization of the cornea, usu- 
ally due to the irritation of trachoma granulations. 
See Cornea (Diseases), Trachoma. 
PANOPHTHALMITIS.-Inflammation of all the 
tissues of the eyeball. It is a purulent irido- 
choroiditis resulting in abscess formation. There 
is protrusion of the eyeball and perforation of the 
coats. 
PANTOPON.-A preparation said to contain all 
the alkaloids of opium in the form of chlorids; 
dose one quarter of a grain 
PAPAIN.-A proteolytic ferment obtained from 
papaw-milk, the juice of Carica papaya, a tree 
native to South America. It has the digestive 
properties of pepsin, but is far more active, dissolv- 
ing fibrin in neutral, acid, or alkaline liquids. It is 
an excellent solvent of false membranes. Papayo- 
tin and caricin are other names for the ferment. 
Dose, 1 to 3 grains. 
PAPAVER.-The poppy, the juice and extracts 
of which possess narcotic properties. Opium is 
obtained from P. somniferum. See Opium. 
PAPAVERIN.-An alkaloid found in opium. It 
is narcotic, and produces primarily muscular 
relaxation; later, convulsions. It stands midway 
between morphin and codein in its action on the 
central nervous system, but it is a comparatively 
weak poison. 
PAP AW.-See Papain. 
PAPAYOTIN.-See Papain. 
PAPER.-Paper has been introduced into sur- 
gery as a substitute for lint on account of its cheap- 
ness. Porous varieties resembling blotting paper, 
and capable of absorbing a large amount of fluids, 
have been manufactured; hence, it is suitable for 
applying wet dressings, as lead-water and laud- 
anum, etc. When once saturated, owing to its 
friable character, it cannot be reapplied. Waxed 
paper, made by immersing sheets of tissue paper 
in hot wax or paraffin, which, when cooled, forms 
a thin coating that makes it impervious to water 
is universally employed in hospital practice as a 
subtitute for oiled silk; owing to its cheapness it 
can be destroyed after each application. Because 
of its extreme thinness it is advisable to use several 
layers, otherwise the moisture soon makes its way 
through. Parchment paper has been introduced as 
a substitute for mackintosh in the Lister antiseptic 
gauze dressing. When first removed from the pack- 
age, it is soft and pliable, but on drying becomes 
crisp. The paper, when applied over wet dressings 
to prevent the escape of moisture, appears to fulfil 
all purposes for which oiled silk has served. 
Paraffin paper is employed as a dressing in some PAPILLITIS 
PARALYSIS, ACUTE ASCENDING 
forms of skin-disease accompanied by crusting and 
exfoliation, with the object in view of macerating 
the skin and thus loosening the products of disease. 
In other cases it is employed as a protector. 
Paper is valuable in applying ointments and moist 
dressings. It is superior to rags and cloths. The 
paper is to be cut into pieces of the appropriate 
size, spread with the selected ointment, and closely 
applied to the surface, being kept in place by a 
bandage. In affections of the fingers and toes, as 
well as the limbs generally, paraffin paper is easily 
adapted to the inequalities of the skin surfaces. 
The fact that it soon becomes friable and torn is an 
advantage, as it insures more frequent change of 
dressings, and consequent cleanliness. 
Blotting paper rolled between the fingers and 
introduced into the nostrils is recommended by 
Sajous for removal of secretion from nasal pas- 
sages in young children. It has been suggested 
also as a material for making tampons for arresting 
nasal hemorrhage. 
Before soaking in a solution of nitrate of potash, 
paper should be cut in strips 3 inches long by 1/2 
inch broad. It is next dipped in the solution in a 
cylindric vessel 4 inches high and 2 inches in dia- 
meter. The paper should then be ignited and the 
smoke inhaled by repeated deep inhalations. 
Nitrated papers, according to Lefferts, should be 
kept in tin-foil or prepared in small quantities, as 
required. See Potassium Nitrate, Charts. 
PAPILLITIS.-Inflammation of the optic disc or 
papilla of the eye. The old terms, choked disc, 
descending neuritis, etc., implied unproved theories 
of causation, and have been replaced by the adop- 
tion of the better term, papillitis. Intracranial 
diseases, as tumors, meningitis, abscess, etc., are 
the most frequent causes. See Optic Neuritis. 
PAPILLOMA.-A term loosely employed to 
include corns, warts, horns, and certain naevi. 
Papillomata stand midway between true tumors 
and inflammatory growths; a papilloma is any 
growth on the skin or mucous membrane based 
upon, or resembling, a normal papilla. A hard 
papilloma is a form in which the connective-tissue 
framework is denser and the cells fewer than usual. 
It grows chiefly from the skin. A soft papilloma 
is one growing from mucous membranes, especially 
in the uterus, rectum, and bladder. See Corn, 
Tumors, Warts. 
PAQUELIN CAUTERY.-See Cautery. 
PARACENTESIS.-Piercing or tapping a cavity 
of the body, such as the chambers of the eye, the 
membrana tympani, the abdomen, or the thorax, 
for the evacuation of fluid. See Ascites, Cornea 
(Operation), Ear, Pericarditis. 
PARADOXIC CONTRACTION.-See Nervous 
Diseases (Examination). 
PARALDEHYD. C6H12O3.-A polymeric form 
of acetaldehyd. It is a colorless liquid of repulsive 
odor and unpleasant taste. It is a reliable hypnotic, 
and is diuretic. It is valuable in delirium tremens, 
mania, tetanus, and other nervous affections. Dose, 
20 minims to 2 drams. It will dissolve trional, and 
this solution forms a powerful hypnotic.- 
Paraldehyd Habit.-The morbid addiction to 
the use of the drug gives rise to symptoms similar 
to delirium tremens. Emaciation, anemia, weak- 
ness and irregularity of the action of the heart- 
gastric derangement, costiveness, general tremul, 
ousness, especially in the tongue, facial muscles, 
and hands, feebleness and unsteadiness of gait, 
general restlessness, paresthesia, insomnia, mental 
anxiety and agitation, mental confusion, mental 
excitement, temporary loss of memory, incoherence 
of speech, hallucinations, delusions. The odor of 
paraldehyd may be appreciable in the breath. 
Treatment requires about 3 months in an inebriate 
asylum. 
PARALYSIS.-Loss of the power of voluntary 
motion. Paresis is simple weakening of such 
motor power. 
By monoplegia is meant isolated paralysis of 
one part of the body, as an arm or leg. By 
hemiplegia is meant paralysis of the entire half 
of the body, including half of the face, one arm, 
and one leg, also known as unilateral paralysis. 
By paraplegia is meant simultaneous paralysis 
of corresponding halves of the body. Paralysis 
of the two arms is spoken of as superior paraplegia, 
of the two legs as inferior paraplegia, while the 
word paraplegia alone is often used for the latter 
condition. Diplegia is paralysis with spasm of all 
the extremities. 
Impairment of voluntary muscular power must 
be the result of structural change in the motor 
area of the cortex, in the great motor tract of the 
brain or cord, or impairment in the integrity of the 
efferent nerves, or it may be more rarely, in the 
muscle itself, "myopathic palsy;" or the power 
of the will may be abrogated. In diseases of the 
peripheral nerves, when the paralysis is called 
peripheral, it is limited to the region of distribution 
of the affected nerves, whether one or many. 
It may be said in general that hemiplegia is the 
usual form of cerebral paralysis, while paraplegia 
is the expression of spinal paralysis. Monoplegias 
are usually due to lesions of the cortex or are 
peripheral palsies. 
In all hemiplegias caused by lesions above the 
pons, the palsy, including face and extremities, 
is on the side opposite the lesion, but in most 
lesions in the pons there is crossed paralysis-that 
is, there is paralysis of the extremities on one side 
and of the face on the other side, because the fibers 
of the facial nerve cross much higher than the fibers 
to the extremities. The result is a paralysis of 
the face on the same side with the lesion, and of 
the extremities on the other. If the lesion is 
higher up, above the decussation of both the facial 
and pyramidal tracts, the paralysis is on the side 
opposite the lesion, in both face and extremities. 
Other nerves may substitute the facial in this 
crossed paralysis, as the hypoglossal or abducens. 
In rarer instances there may be lesion at the very 
decussation of the pyramid, cutting the motor 
fibers of one extremity before they cross, and those 
of another after crossing, producing the very rare 
condition of paralysis of an arm on one side and 
leg on the other (Tyson). See Brain, Muscles, 
Nerves, Spinal Cord. 
PARALYSIS, ACUTE ASCENDING (Landry's 
Paralysis).-A rare disease characterized by paral- PARALYSIS AGITANS 
PARALYSIS, BULBAR, PROGRESSIVE 
ysis appearing suddenly in the feet and ascending 
rapidly to the other muscles of the body, and finally 
involving the medulla. The paralysis is ordinarily 
preceded by a prodrome including anorexia, 
malaise, fever, pain in the head and back and ting- 
ling in the extremities. There are no pain and no 
trophic changes; the knee-jerk is usually dimin- 
ished; sensation is generally preserved, but there 
may be hyperesthesia and muscular tenderness; 
the special senses are unaffected; the sphincters are 
uninvolved. The spleen may be enlarged. The 
paralysis is a flaccid one, the muscles are relaxed 
but do not atrophy or yield reactions of degenera- 
tion because of the rapidly fatal termination. 
The pathology is obscure, and the malady is a very 
fatal one, usually terminating in death within a 
week, although it may continue for 3 or 4 weeks. 
Recovery, however, has occurred in some cases. 
Males are more frequently attacked than females, 
and the affection occurs chiefly between the ages 
of 20 and 40 years. 
Diagnosis.-Acute myelitis is distinguished 
from Landry's paralysis by the wasting, anesthesia, 
electrical changes, early involvement of the 
sphincters. In multiple neuritis there are marked 
sensory disturbances. 
Treatment.-Rest in bed is essential. Dry or 
wet cups should be applied to the spine and counter- 
irritation kept up by a mustard plaster. Paquelin's 
cautery may be tried. Ergotin (10 to 20 grains a 
day), salicylates, perchlorid of iron, iodid of 
mercury, are all recommended. 
PARALYSIS AGITANS (Shaking Palsy; Parkin- 
son's Disease).-An affection marked by tremor or 
alternate contraction and relaxation of the muscles 
of the part involved. 
Symptoms.-The movements are regular and 
rhythmic (in distinction from insular sclerosis), 
and begin usually in one hand. They almost never 
affect the head. They persist during rest, and are 
little influenced by voluntary movement. Later 
in the disease there is a typical gait, known as 
festination or propulsion. It consists in a progres- 
sive increase in the rapidity of the gait until the 
patient breaks into a run, which grows faster and 
faster until he either falls or seizes some support. 
This peculiar gait is ascribed to the bent position of 
the trunk, which throws the head so far forward 
as to bring the center of gravity beyond the line 
of the feet. Rarely the movement is backward: 
this is called retropulsion. It may be to one or 
the other side-lateropulsion. The speech is 
slow, monotonous, and high-pitched. The face 
is fixed and expressionless. In advanced stages 
there is an almost statue-like rigidity of the body. 
The hand assumes a peculiar position, as if rolling 
a small body between the thumb and the fingers, 
but later the position becomes constant, similar to 
that in which the pen is held-hence, the term of 
writing hand. The knee-jerk may be exaggerated. 
Flushing and heat are sometimes complained of. 
Paralysis agitans is most common in males over 
40 years of age. 
Diagnosis.-Disseminated sclerosis exhibits a 
tremor, but only of voluntary movements-inten- 
tion tremor. There are also scanning speech and 
ataxic gait, with mental enfeeblement, as shown 
by an unnatural contentment with the physical 
condition and surroundings. 
Chorea displays a tremor, but the movements 
are general, and particularly involving the muscles 
of the face. Again, chorea is a disease of children 
and young adults. See Chorea. 
The course is of long duration, the disease at 
times lasting 20 or 30 years. 
The lesion is probably a diffuse sclerosis of the 
brain and spinal cord. 
Treatment.-The patient should receive rest, 
bodily and mental. Nutritious food, cod-liver 
oil, hypophosphites, or arsenic should be adminis- 
tered. Hyoscyamin sulphate, 1/30 to 1/10 grain, 
3 times daily, is a valuable remedy. Good results 
have followed the use of hyoscin hydrobromid, 
1/200 to 1/100 grain, 3 times daily. Mild galvan- 
ism, 2 or 3 times a week, acts as a nerve-stimulant. 
PARALYSIS, BELL'S.-See Facial Paralysis. 
PARALYSIS, BULBAR, ACUTE.-This paralysis 
is the result of hemorrhage into the medulla or pons, 
or of thrombosis or embolism of the vessels sup- 
plying these centers. The symptoms are sudden; 
in addition to those of the progressive or chronic 
type there may be loss of consciousness, deranged 
cardiac and respiratory action, high fever. If 
the motor tract is involved there is the peculiar 
crossed paralysis that usually accompanies hemor- 
rhage into the pons-paralysis of the face on one 
side and of the extremities on the other. 
PARALYSIS, BULBAR, ASTHENIC (Erb's 
Disease, Myasthenia Gravis, Hoppe-Goldflam 
Symptom Complex).-A chronic disease character- 
ized by progressive loss of muscular power affect- 
ing first the muscles of the eye, face, neck, tongue, 
larynx. The muscles involved become rapidly 
fatigued on effort, but regain power temporarily 
after rest. A similar effect obtains on faradiza- 
tion of the muscles (Jolly's myasthenic reaction). 
Treatment consists in prolonged rest, massage, 
galvanization of muscles, liquid food, tonics. 
PARALYSIS, BULBAR, PROGRESSIVE (Glosso- 
labiolaryngeal Paralysis, Atrophic Bulbar Paral- 
ysis).-A form of paralysis due to a degeneration 
of the nuclei of origin of the nerves (facial, glosso- 
pharyngeal, vagus, spinal accessory, and hypo- 
glossal) arising in the oblongata. Bulbar symp- 
toms may precede or follow spinal symptoms. 
A similar condition affecting the eye muscles is 
called progressive ophthalmoplegia. 
Etiology.-The condition is sometimes a sequel 
to exposure to severe cold; it may be caused by 
morbid growths or by syphilis. Rheumatism, gout, 
and neck traumatisms are also causes. 
It is usually confined to the latter half of life, 
and its prognosis is bad. 
Symptoms.-At first only the muscles of the 
lips, tongue, and pharynx are affected. The 
disease is marked by difficulty in mastication, 
deglutition, respiration, phonation, and articula- 
tion, and by wasting of the muscles concerned in 
the performance of these functions. 
Treatment is entirely symptomatic. Galvanism 
is the most promising remedy. Stabile applica- 
tions, the electrodes on the mastoid processes and PARALYSIS, CEREBRAL 
PARALYSIS, GENERAL, OF INSANE 
in the opposite direction, galvanization of the 
sympathetic, and applications to the lips, tongue, 
and fauces should be persistently used. Anti- 
syphilitic remedies should be administered in all 
suspicious cases. General tonic and hygienic 
treatment is indicated. 
PARALYSIS, CEREBRAL.-See Brain (Hem- 
orrhage, Tumors, etc.). 
PARALYSIS, DUCHENNE'S.-A chronic disease 
characterized by progressive muscular weakness, 
associated with an apparent hypertrophy of the 
affected muscles. There is an interstitial fibrous 
overgrowth of the muscles, frequently accom- 
panied by an accumulation of fat and atrophy of 
the true muscle-fibers. The disease usually begins 
in the muscles of the calf, and spreads over the 
body, the muscles of the hand almost always escap- 
ing. There are marked lordosis and a character- 
istic gait, with wide separation of the legs and 
swaying of the body from side to side. The char- 
acteristic symptom is the manner in which the 
patient rises from the floor-he " climbs" up on his 
legs, on account of the weakened state of the ex- 
tensor muscles of the back. The disease is essen- 
tially a chronic one, but the patient becomes 
absolutely helpless long before death. It is 
most common in young male children, usually 
under 10 years of age. The disease is entirely 
myopathic, no adequate nerve-lesion having as 
yet been discovered. 
PARALYSIS, GENERAL, OF INSANE (Paretic 
Dementia).-An organic disease of the brain, 
characterized by progressive loss of power and by 
a deterioration of the mental faculties, ending 
eventually in dementia and death. The dur- 
ation varies from a few weeks or months to three 
or more years, being, on the average, longer in 
females than in males, and in the well-to-do than 
in the poor. 
Etiology.-The affection is most common in 
males between the ages of 30 and 60. It is induced 
by overwork and mental and physical strains, 
intemperance, syphilis, and lead-poisoning. 
The lesion is essentially a meningoencephalitis, 
with thickening of the cerebral meninges and 
wasting of the cortical substance. 
Symptoms.-In most cases mental symptoms 
precede distinct motor ones. General paralysis 
does not supervene in ordinary insanity. The 
mental symptoms occur in the most varied possible 
time and mode of sequence. The moral feeling, 
perturbed at first, rapidly undergoes disintegra- 
tion and decay. After a preliminary despondency, 
the emotional state tends to be gay; later, to be 
depressed, morose, or peevish, and finally to die 
out. More or less dementia is present in all cases 
from the early stages, is irregularly progressive, 
and often very extreme toward the close. 
Three stages are marked: (1) A period of mental 
alienation, associated with fibrillar tremblings, 
noticeable in the tongue and facial muscles; (2) a 
period of chronic mental failure and bodily decay; 
(3) a stage of complete mental ruin, in which there 
is failure of motor, sensory, and nutritive functions. 
In the first stage there is much difficulty in 
deciding as to the nature of the disease, there being 
some alteration in the moral nature before friends 
notice any bodily defect, so that a gradual altera- 
tion in character may take place. The principal 
mental symptoms are alterations in demeanor, 
conduct, temper, and disposition, enfeeblement of 
memory and loss of power in the highest acquire- 
ments, especially if the latter demand much skill 
and originality. 
The principal body signs and symptoms in the 
early period are some defect of sight, hearing, or 
smell. The onset may take any clinical form, as 
maniacal, melancholic, stuporous, or of the nature 
of dementia. Delirium of exaltation is a very 
frequent symptom. Whatever the form of onset, 
dementia is the natural tendency of the disease, 
and, therefore, loss of memory and filthy habits 
are likely to occur with much greater frequency 
than in ordinary melancholia. 
The characteristic motor signs may be masked, 
and usually consist of increased difficulty of speech, 
stoppage or stuttering, or great effort to enunciate, 
associated with marked twitching of the lips or 
face. Great loquacity exists in the expansive 
forms, but amnesia is most often seen. A loss of 
expression in the lower part of the face, the lines 
being smoothed out, is found; the tongue is pro- 
truded with difficulty, or is jerked out and suck- 
ing; swallowing or masticatory movements are 
common. 
In the second stage physical signs become more 
marked and speech more incomprehensible, the 
appetite is voracious, face expressionless, gait 
feebler, and the general condition worse. 
In the third stage the extreme of mental and 
physical deterioration is reached, and the patient 
is bedridden. 
Severe cases may end in death in a week, but 
the average duration is over 2 or 3 years, some 
cases lasting 10 to 15 years; is longer in females 
than in males, and in quite demented cases and in 
those of hereditary tendency. 
Diagnosis.-General paralysis is frequently 
overlooked. Moral perversions are common, but 
distinct change in character in a man in middle 
life, especially if he has been active in business, 
should excite suspicion. From ordinary acute 
mania or other forms of insanity the diagnosis is 
difficult in the early stages, but made certain by 
the occurrence of motor symptoms. Acute mania 
from alcoholic excess may resemble general 
paralysis at the onset, especially if associated 
with exaltation and tremors. Syphilitic disease 
of the brain or meninges may simulate the de- 
mented forms of general paralysis. From the 
monomania of grandeur, the speech, and other 
motor symptoms, the more changeable nature of 
the exaltation and the course of the disease, 
differential diagnosis is made. Intracranial tu- 
mors sometimes cause simulation of the demented 
form of this disease. Disseminated sclerosis, 
dementia associated with hemiplegia or other 
paralyses, and paralysis agitans may possibly be 
confused with general paralysis. Epileptiform 
seizure frequently marks the onset of general 
paralysis, but true epilepsy is said never to be 
followed by the latter. Plumbism and excessive PARALYSIS, INFANTILE CEREBRAL 
PARALYSIS, INFANTILE SPINAL 
use of bromids may give rise to conditions simulat- 
ing general paralysis. 
Prognosis.-The disease is practically incurable 
when the characteristic symptoms have developed. 
Treatment.-In the earliest stage complete ces- 
sation of all causes of emotional or mental strain 
may act beneficially, but instead of rest, attempts 
to stimulate to cheerfulness are usually made. No 
drugs appear to have any effect in cutting short 
the disease. Antisyphilitic remedies may be tried 
in appropriate cases. General paralytics are very 
susceptible to powerful drugs, and such should be 
used with caution. A return to home-life acceler- 
ates the final break-down, especially if followed 
by attemps at sexual intercourse or indulgence in 
any form of excess. 
PARALYSIS, INFANTILE CEREBRAL. Syno- 
nyms.-Spastic hemiplegia, diplegia, or paraplegia. 
Infantile Spastic Hemiplegia.-In most in- 
stances this paralysis is of the acute, acquired 
type, developing at any time after birth but usu- 
ally before the fifth year. 
Etiology.-It may be due to abnormal condi- 
tions or accidents or disease (especially syphilis) 
of the mother during pregnancy; it may be the 
result of lesions during delivery. After birth it 
may be caused by traumatism, embolism, scarlet- 
fever, pneumonia, measles, diphtheria, variola, 
mumps, typhoid fever, meningitis. It is very 
often brought on by pertussis. Convulsions may 
be the cause or the result of the lesion. 
Pathology.-There may be hemorrhage, em- 
bolism or thrombosis. The main lesions found at 
autopsy are sclerosis and atrophy. 
Symptoms.-The onset is sudden with convul- 
sions, which are usually repeated, and coma. In 
exceptional cases the hemiplegia may come on 
suddenly in apparently well children. Fever is 
usually present, with delirium and vomiting. As 
the child recovers consciousness the paralysis is 
discovered usually complete though sometimes it 
is at first only paresis. If the face is involved, it 
soon recovers. Power is gradually restored in 
several weeks to the leg though in most cases a 
persistent halt remains, but the arm recovers so 
slowly that contractures are apt to develop in 
several years and moderate atrophy ensues. There 
is more or less rigidity as a rule, lessened during 
sleep and increased by excitement and attempts 
to overcome the spasm. Aphasia is common in 
right hemiplegias and is found too in left. Elec- 
trical reactions are usually normal. Disturbances 
in sensation are slight and transient. Posthemi- 
plegic chorea or athetosis is often found. The 
mental condition is often defective though it may 
be normal. Epilepsy is a frequent sequel. 
Infantile Spastic Diplegia. Synonyms.-Bilat- 
eral infantile spastic hemiplegia; Little's disease; 
spastic rigidity of the new-born; birth palsies. 
Etiology.-The causes are the same as of in- 
fantile hemiplegia. Most cases date from birth and 
are due to lesions during delivery. The lesions are 
bilateral and involve practically only the motor 
areas of the cortex. Usually the primary cause 
of cerebral birth paralysis is meningeal hemorrhage. 
From the resulting blood-clot or from meningo- 
encephalitis, sclerosis or porenceplialous defect 
follows. 
There may be convulsions, often a series, after 
birth. In mild cases, however, the first symptom, 
limpness of the muscles, may be noticed only after 
6 or 8 months. This flaccidity is often mistaken 
for rickets. Some rigidity of the legs and exag- 
gerated knee-jerks will be found later. Athetoid 
or choreic movements are seen frequently. Men- 
tal defect is usually present. 
Infantile Spastic Paraplegia.-Etiology is the 
same as in the preceding types, with the additional 
factor premature birth. 
Symptoms.-The spastic paralysis of the lower 
extremities dates from birth or the first years of 
life. There is talipes equinus or equinovarus, 
adductor spasm, rigid gait and no muscular at- 
rophy. There may be slight or no mental defect. 
Diagnosis.-Infantile cerebral paralysis must 
be differentiated from infantile spinal paral- 
ysis (see below). Spastic diplegia and paraplegia 
are distinguished from pseudoparalytic rigidity 
and tetany by the history-existing from birth; 
the parts involved: the legs almost to exclusion of 
arms; by the painless character of the spasm; and 
by the continuous duration. 
Prognosis.-This is grave in diplegia and para- 
plegia. The majority of these due to intrauterine 
or birth lesions die in infancy, the rest usually 
are feeble-minded and helpless. The outlook is 
brighter in hemiplegia; the onset being later the 
brain is less apt to be injured seriously. The resid- 
ual paralysis may be so slight that there may be 
no suspicion of a previous paralysis until the occur- 
rence of epilepsy. 
Treatment.-The stage of convulsion should be 
treated by chloral, absolute rest, ice to the head. 
The established paralysis is for the most part in- 
tractable, but baths, hygiene, gymnastics, good 
food, manipulations, surgical appliances, electric- 
ity, may be used. If mentally deficient, the 
child should be placed in an institution for the 
feeble-minded. 
PARALYSIS, INFANTILE SPINAL. Acute An- 
terior Poliomyelitis; Acute Atrophic Paralysis.- 
A disease peculiar to childhood, and characterized 
by sudden paralysis of one or more limbs or of 
individual muscle-groups, and followed by rapid 
wasting of the affected parts, with reaction of 
degeneration and deformity. Acute poliomyelitis 
is the most frequent cause of paralysis in early 
life. 
The disease may occur in adults, under thirty, 
though rarely. When it does, the symptoms are 
the same as in children; care, however, should be 
taken not to confound it with multiple neuritis. 
Etiology.-This form of paralysis occurs most 
frequently during the first three years of life, very 
rarely after the fifth year. In a large proportion 
of cases the disease appears during the hot summer 
months, although it may occur at any time. It is 
now known to be due to an acute infection, the 
causative agent being a filterable virus. The virus 
is transmitted by the stable fly, and probably by 
the bed bug and common fly. 
Pathology.-Infantile spinal paralysis is due to PARALYSIS, INFANTILE SPINAL 
PARALYSIS, PSEUDOHYPERTROPHIC MUSCULAR 
an inflammation of the gray matter of the anterior 
portion of the spinal cord. The region of the cord 
most commonly involved is the lumbar enlarge- 
ment, and usually only one lateral half of the cord 
is affected. It is thought that the first changes 
are in the blood-vessels, from which the process 
spreads to the neuroglia, and produces prolifera- 
tion of cells early, but later atrophy of the gang- 
lion cells. In cases of long standing the part of the 
cord affected is distinctly smaller than normal. 
The affected muscles degenerate, the fibers be- 
coming small or disappearing entirely, their place 
being taken by adipose and fibrous tissue. The 
affected limb is shorter and the bones smaller than 
upon the sound side. 
Symptoms.-The onset is sudden, and marked 
by fever, vomiting, convulsions, or even coma. 
The fever usually varies from 102° to 104° F., but 
some cases occur without any rise of temperature. 
In the great majority of cases it is, however, one of 
the first, and often the only, symptom which will be 
noticed. It generally lasts for 24 or 48 hours, 
though in some cases in which all the symptoms 
show marked severity it may continue for a week. 
In most cases there are pains in the back and in 
the muscles of the extremities and a general hyper- 
esthesia. There may be other disturbances of 
sensation, such as numbness and tingling. 
As the symptoms of invasion gradually subside, 
the paralysis comes on. The development of the 
paralysis is quite rapid, often attaining its maxi- 
mum in 24 hours, although sometimes it will be 2 or 
3 days, or even a week, before its full extent is seen. 
At the start it is usually widely distributed, often 
involving all four extremities, but most frequently 
but one or two. The muscles of the trunk may be 
affected also, but the respiratory muscles usually 
escape. 
Within a period of 1 or 2 weeks the initial wide- 
spread paralysis diminishes for several weeks, 
after which time little improvement takes 
place and the muscles then affected remain 
so permanently. Marked atrophy will soon be 
noticed in the paralyzed muscles, and the affected 
limb becomes distinctly smaller and shorter than 
its fellow. The electric reaction is important; 
with rare exceptions the affected muscles and the 
nerves supplying them exhibit a complete reaction 
of degeneration. The permanent paralysis may 
involve one or more parts of the body, but the 
lower extremities are much more frequently af- 
fected than the upper. 
The most frequent deformities resulting from 
the paralysis are talipes valgus and varus, but 
most of the patients are able to walk with the 
assistance of braces. 
Diagnosis.-The general symptoms at the onset 
have nothing characteristic about them, and no 
diagnosis can be made until the paralysis occurs. 
The acute onset, the spontaneous improvement 
in certain groups of muscles, the rapid wasting 
of those which are permanently affected, the ab- 
sence of sensory symptoms, and the reaction of de- 
generation, all constitute a type which should not 
be mistaken. 
In that epidemic form of poliomyelitis which so 
closely resembles epidemic meningitis, lumbar 
puncture should be performed in order to obtain a 
correct diagnosis. 
The following table gives the principal points of 
difference between this disease and acute cerebral 
palsy: 
Acute Spinal Paral- 
ysis. 
Onset sudden, with fever, 
coma and convulsion. 
Convulsions rarely r e - 
peated after first few 
days. 
Paralysis flacid, associ- 
ated with rapid 
atrophy. 
Paralysis usually widely 
distributed. 
Electric reaction altered. 
Deep reflexes diminished 
or lost. 
Intellect never perma- 
nently involved; n o 
epilepsy. 
Acute Cerebral Par- 
alysis. 
The same. 
Convulsions likely to 
be repeated. 
Paralysis spastic. No 
rapid atrophy asso- 
ciated with rigidity 
and contractures. 
Paralysis generally 
hemiplegic. 
Normal. 
Exaggerated. 
Often involved; epi- 
lepsy frequent. 
Prognosis.-The prognosis as regards life is 
favorable, but more or less paralysis will remain. 
In many cases in which the initial paralysis is 
quite general the retrogression may be so extensive 
as to leave but few of the muscles permanently 
affected; this result, however, is to be expected 
more generally when the primary paralysis is not 
widely distributed. Muscles which become atro- 
phied, and which do not respond to the faradic 
current by the end of 6 months, or at longest one 
year, will remain useless. 
Treatment.-During the initial stage the treat- 
ment is that of all febrile affections. Rest in bed, 
restricted diet, a laxative dose of calomel, small 
doses of phenacetin or acetanilid, if the nervous 
symptoms are marked, and sponge bathing for the 
nervous symptoms and the fever. When the 
nature of the disease is positively shown by the 
onset of paralysis, absolute quiet is essential. An 
ice-bag should be placed along the spine, or mild 
counterirritation to the spine by mustard plasters 
may be practised. No medicines are cura- 
tive, and the remedies used should be directed 
to keeping up the general nutrition of the child. 
After all acute symptoms have subsided, electricity 
should be used. The faradic current should be 
applied to the affected muscles from 8 to 10 min- 
utes every other day, or daily for months. Mas- 
sage, probably, is more beneficial than electricity in 
aiding the nutrition of the muscles. The patient 
should be encouraged to use the weakened limb, 
which must be warmly clad and carefully protected 
from cold. Much may be done in the chronic 
stage by mechanic appliances to correct the de- 
formities and support the limb. In others, surgi- 
cal measures, as myotomy, tenotomy, etc., must be 
resorted to. 
PARALYSIS, PSEUDOHYPERTROPHIC MUS- 
CULAR.-See Muscules (Progressive Dystrophies). PARALYSIS, SPASTIC SPINAL 
PARASITES 
PARALYSIS, SPASTIC SPINAL.-See Lateral 
Sclerosis. 
PARAMYOCLONUS.-The convulsive tremor 
of Friedreich, a functional neurosis marked by the 
sudden shock-like character of the muscular con- 
tractions, their bilateral symmetry, and the free- 
dom of the extremities. There is no ataxia, par- 
alysis, or anesthesia; electric irritability is normal; 
consciousness is unimpaired; the convulsive move- 
ments are usually in abeyance during sleep. The 
disease generally occurs in males, and manifests 
itself both in children and in adults. It is sup- 
posed to be caused by fright or physical overstrain. 
Paramyoclonus multiplex is an affection char- 
acterized by clonic contractions, chiefly of the 
muscles of the extremities, occurring either con- 
stantly or in paroxysms. It occurs usually in 
males, and follows emotional disturbance, fright, 
or straining. The contractions are usually bilat- 
eral, and may vary from 50 to 150 a minute. 
PARANOIA (Monomania).-A chronic mental 
disease, characterized by fixed logical or system- 
atized delusions of persecution, unseen or impos- 
sible agencies, or of self-exaltation, the emotions 
and memory being only paroxysmally defective, 
while, however, the life of the individual is domi- 
nated by the delusions. The term paranoia, as it is 
now commonly used-to cover a group of insan- 
ities which are degenerative in origin, chronic in 
course, and characterized by systematized delu- 
sions, with little impairment of the emotional 
faculties-is not generally accepted as a synonym 
for monomania. There is generally a hereditary 
predisposition to insanity in monomania or 
paranoia. The exciting cause may be the result 
of an acute mania or melancholia, or the result of 
alcoholism or of malnutrition in those who have 
had a struggle to keep their position in the world; 
extreme worry in individuals with mental in- 
stability; following primary or acute delusional 
insanity. 
Symptoms.-The course of monomania is essen- 
tially chronic, the delusions becoming perfectly 
fixed and unchanging upon one particular subject 
or set of subjects, which in turn dominate the life 
of the individual. Most commonly these systemat- 
ized delusions are delusions of persecution or 
suspicion, delusions of exaltation or of pride, and 
delusions of unseen agencies. 
Diagnosis.-In the diagnosis of monomania 
there are three points to keep in mind: (1) The 
duration: the fixed, systematized delusions must 
have existed over one year. (2) The absence of 
symptoms of mania or melancholia. (3) The 
presence of systematized delusions affecting the 
personnel of the individual. 
Monomania is an incurable disease. Unless 
tuberculosis develops within a few years, dementia 
results. 
Treatment is symptomatic. The best hygienic 
conditions are demanded. See Mania. 
PARAPHIMOSIS.-Retraction and constriction 
of the prepuce behind the glans penis. See Penis. 
PARAPLEGIA, ATAXIC (Posterolateral Scler- 
osis, Gowers' Disease).-Degeneration of the poste- 
rior and lateral columns of the cord. The etiology 
is unknown. Syphilis, heredity, neurotic tendency 
seem to be factors. It is always associated with 
general paralysis of the insane. The symptoms 
resemble spastic paraplegia in the loss of power and 
muscular rigidity and tabes dorsalis in the marked 
incoordination. The reflexes, however, are exag- 
gerated, including ankle clonus and kn6e-jerk. 
The sphincters are sometimes involved. Treat- 
ment is chiefly symptomatic. See Paralysis. 
PARASITES.-Parasitism is essentially a condi- 
tion of infestment of some form of life by another 
living organism, usually of lower type. The para- 
site is the invading form, whether animal or vege- 
table, and is spoken of as either an ectoparasite, if 
living upon the surface, or as an endoparasite, if 
inhabiting some part of the internal structures of 
the invaded organism. The latter is spoken of as 
the autosite, or host; and when in the life of the 
parasite there are special stages in its cycle, the 
host of the fully developed organism is spoken of 
as the primary or definitive host, the one or more 
hosts accommodating the intermediate stages of 
the parasite being denominated the secondary or 
intermediate hosts. Parasites of man are animal 
and vegetable. 
There are three kinds of parasitism: (1) True 
Parasitism. In this condition the parasite does 
harm to the host, and derives all the benefit of the 
association; example, the hook-worm infecting 
man or animals. (2) Mutualism. In this there is 
mutual benefit to each party of the association; 
example, the presence of colon bacilli in the intes- 
tines, where the bacillus is furnished a suitable 
habitat and in return protects its host against 
strictly pathogenic bacteria. (3) Commensalism. 
Here there is benefit to the parasite, but no injury 
to the host; example, the trichomonas vaginalis 
which lives in the vaginal mucus, but, so far as 
is known, does no injury to the host. 
The effects of animal parasitism may be practi- 
cally nil according as the numbers of parasites pres- 
ent are small or the influences of the parasites are 
slight, or according to the part of the host affording 
accommodation to the parasites in question. On 
the other hand, pathogenic influences are exerted 
and anatomical changes and symptoms of variable 
intensity are produced by animal parasites just 
as in case of infection by pathogenic bacteria. 
The irritation caused by the presence and by the 
movements of the parasites, with consequent in- 
flammatory effects, as well as the possibility of 
tissued estruction, pressure atrophy, and second- 
ary degenerations, must be taken into considera- 
tion. The possibility of obstruction of more or 
less important channels, as the occlusion of blood 
or lymph vessels by the ova of blood flukes or the 
embryo filarial worms, as well as a large number 
of similar possible disturbances in other parts of 
the body by one or other form of parasites, must 
from time to time be reckoned with. The ab- 
straction of food-stuff from the economy of the 
host by the parasite cannot be looked upon as of 
serious import in itself, but the possibility of loss 
of valuable matter, as in blood destruction by the 
Animal Parasites. PARASITES 
malarial hematozoon or the loss of blood by hemor- 
rhage from the wounds in the intestinal mucosa 
through lesions caused by hook-worms and other 
sucking parasites, may constitute serious factors of 
disease for the host. Moreover, there, unquestion- 
ably are toxic influences generated in one or other 
manner in animal parasitism which may exert 
marked and deleterious influences upon the in- 
fested organism, as doubtless in malaria, in un- 
cinariasis, bothriocephalus disease and a number 
of other similar affections.-(Tyson.} 
The important classes of animal parasites in 
man are the Protozoa (q. v.), the Worms (q. v.), and 
the arthropods. Of the arthropods the important 
ones are (1) the acarina (mites, ticks), to which 
species belong the acarus scabiei (the itch mite), 
the leptus autumnalis (the harvest bug), and the 
demodex folliculorum (the comedo mite); (2) the 
pediculidce (lice); and (3) the diptera, to which 
belong the fleas and flies. Myiasis is a condition 
due to the deposition of the larvae of flies in open 
sores, or in the nose, ears, eyes, pharynx, or 
vagina. 
Insects and Communicable Disease.-Recent 
studies in communicable diseases have shown that 
certain insects are essential to the propagation of 
some maladies, and incidentally are of importance 
in others. In malaria the mosquito is certainly 
the most important if not the only means by which 
the disease is spread; in this affection the sexual 
cycle of the plasmodium is completed in infected 
mosquitos. It is generally conceded that the 
mosquito is necessary to the propagation of yellow 
fever, the immediate cause of which is not known. 
In malaria and filariasis the animal parasites under- 
go definite cycles of evolution in the interior of the 
insect. In trypanosomiasis the tsetse-fly inocu- 
lates the disease from animal to animal, but, so 
far as at present known, the flagellate parasite has 
no definite cycle within the insect. There are 
reasons for believing that relapsing fevers can be 
transmitted by bedbugs, and that the bites of 
fleas coming from plague-stricken man or animals 
may induce the disease. In another group of 
diseases, including cholera, typhoid, tuberculosis, 
plague, and infections of the types indicated, the 
germ causing the disease may be deposited upon 
the food, and in that and similar ways be conveyed 
from sources of infection to the healthy.-(Coplin.} 
PARIS GREEN 
minutissimum; pinta is due to several fungi of the 
class arpergillus; to this class otomycosis and 
myringomycosis are believed to be due. Sticker 
has found 16 cases of pulmonary disease to be 
caused by the aspergillus fumigatus-aspergillomy- 
cosis. The leptothrix-a long segmented fungus 
-is abundant in the lungs in pulmonary gangrene 
and may cause the formation of patches on the 
tonsil simulating diphtheritic membrane-pharyn- 
gomycosis leptothrica. The leptothrix buccalis is 
thought to play a significant role in the production 
of caries. 
PARASPECIFIC SEROTHERAPY.-See 
Serum Therapy, (Paraspecific). 
PARATYPHOID FEVER.-An infectious fever 
exactly simulating typhoid clinically, but due to a 
bacillus intermediate between the bacillus typho- 
sus and the bacillus coli, called the paratyphoid 
or paracolon bacillus. The Widal reaction is 
negative, but the serum reacts upon fresh cultures 
of the paratyphoid bacillus. 
Diagnosis is based solely on the paratyphoid 
agglutination test. 
Treatment is the same as that of enteric fever 
except that obviously the paratyphoid bacillus or 
its product is used in specific treatment. 
PAREGORIC.-The camphorated tincture of 
opium. It is of especial service in the treatment 
of diarrhea, because it contains a volatile oil and 
camphor, and it is a most common ingredient of 
cough mixtures. 
In bronchitis: 
I). Paregoric, 3 ss 
Tartar emetic, gr. j 
Potassium nitrate, 5 ij 
Bitter-orange water, 3 xij. 
Give 1 teaspoonful every hour when needed 
for the cough. 
In diarrhea: 
I|. Paregoric, 5 iij to iv 
Dermatol (bismuth sub- 
gallate), 5 ij 
Chalk-mixture, add enough 
to make 3 iij. 
Give 1 teaspoonful every hour until relief is 
obtained. 
PAREIRA (Pareira brava).-The dried root of 
Chondrodendron tomentosum, a plant of South 
America. It is diuretic and laxative, and tonic to 
the mucous membrane of the genitourinary 
organs. It is valuable in cystitis, gonorrhea, and 
leukorrhea, and is used internally and locally for 
the bites of poisonous serpents, etc. P., Flext. 
Dose, 10 to 45 minims. P., Infus., unof. Dose, 
1 to 2 ounces. 
PARESIS.-See Paralysis (General). 
PARIS GREEN.-A preparation of copper, 
chemically known as cupric acetoarsenite, and 
used as a pigment for wall-paper coloring and as 
an insecticide. It is highly poisonous; and for 
treatment of the poisoning by Paris green see 
Arsenic. 
Vegetable Parasites. 
The chief forms are the schizomycetes (fission 
fungi) or Bacteria (g. v.); the blastomycetes or 
Yeasts (q. v.); and the hyphomycetes or molds. 
The mold fungi are made of filaments, hyphae, so 
interlaced that they form a network, the mycelium. 
They reproduce by sporulation. Pathogenic molds 
are the direct agents in the production of the follow- 
ing diseases: favus (achorion Schonleinii); thrush 
(oidium albicans); actinomycosis (actinomyces, ray 
fungus); mycetoma (streptothrix madura, one of the 
actinomyces group). The large-spore fungus or 
smallspore fungus to which ringworm is due has 
been shown to be not a common mold, but a specific 
fungus. Tinea versicolor is due to the microsporon 
furfur; erythrasma is caused by the microsporon PARONYCHIA 
PARONYCHIA (Whitlow).-An abscess of the 
thumb or fingers. 
The superficial whitlow consists of inflammation 
of the surface of the skin of the last phalanx, with 
burning pain or effusion of a serous or bloody 
fluid; it is generally seated immediately around 
and beneath the nail; it is attended by great pain 
and throbbing, and suppuration at the root of the 
nail, which may come off. The deep-seated 
variety, or tendinous whitlow, as it is called, is 
attended by severe, throbbing pain, exquisite 
tenderness, light but tense and resisting swelling, 
and very great constitutional disturbance. It 
may lead to suppuration, the pus extending along 
muscles and tendons from the fingers to the palm, 
and even to the forearm, causing sloughing of the 
tendons, with severe irritative fever, sometimes 
placing life in danger, and frequently leaving the 
limb stiff and useless. 
If purgatives and fomentations do not speedily 
bring relief, the finger must be freely laid open. 
The knife, used early, should be carried deep 
enough to feel the resistance of the bone or tendon; 
the sheath of the latter should be thoroughly laid 
bare. If the matter has extended to the hand, an 
opening should be made until complete drainage is 
established. See Nails (Diseases). 
PAROOPHORITIC CYSTS.-See Ovary 
(Diseases.) 
PAROTID DUCT, DIVISION.-See Face 
(Injuries). 
PAROTITIS.-Inflammation of the parotid 
gland, commonly called Mumps (q. v.). 
PAROVARIAN CYSTS. See Ovary (Diseases). 
PARSLEY.-A biennial plant, from the fruit 
of which is extracted apiol, a nonvolatile, oily 
liquid, of green color, acid reaction, and pungent 
taste; it is often found in commerce as an impure 
oleoresin. See Apiol. 
PARTURITION.-See Labor. 
PARULIS.-See Alveolar Abscess. 
PASTEURIZATION.-See Milk (Pasteurized). 
PASTILLES.-See Troches. 
PATELLA.-See Knee-joint (Injuries). 
PATHOLOGIC TECHNIC.-In this epitome, 
much of which is founded on the admirable work 
of Mallory and Wright on "Pathologic Technic," 
there are given very briefly the fundamental 
practical points. The subject is elaborated more 
fully under such special headings as Bacteriology, 
Blood (Examination), Feces (Examination), 
Microscope, Postmortem Examination, Sputum, 
Urine (Examination), etc. In addition special 
pathologic technic is discussed under the headings 
of certain diseases, as Gonorrhea, Tuberculosis, 
Typhoid Fever, etc. 
Examination of Fresh Material. 
This may be examined after being teased apart or 
in sections. 
Teased Preparations.-Place a small section on 
a glass slide, and cover with a normal salt solution, 
and tease apart by means of two sharp needles. 
Sections of Fresh Specimens.-Freeze the speci- 
men by the evaporation of ether, and shave off a 
small section by means of the blade of a carpenter's 
plane, allowing the specimen to fall into a normal 
saline solution. It should be spread out on a 
slide while remaining in the solution, then dried 
by blotting paper, and immediately examined. 
If it is desired to stain the specimen, add a few 
drops of Loeffler'salkaline methylene-blue solution, 
wash in water, and examine. Oil or fat in the 
fresh specimen may be demonstrated by means 
of a 1 percent solution of osmic acid. 
Cover-glass Preparations.-Such preparations are 
usually made in examining blood, sputum, or 
other fluid or semifluid substance. In the cash of 
sputum a tiny mass is placed on a cover-glass, 
another is pressed gently down upon this, and the 
two glasses are separated by sliding one over 
the other, the object being to secure a thin, even 
film on each glass. The film may also be spread 
with the edge of a cover-glass or with a platinum 
spatula. The preparations are then left to dry 
in air, or they may be dried by exposing them 
to a temperature of 120° F. for 20 minutes, or by 
passing them quickly 3 times through the flame 
of a spirit-lamp or Bunsen burner. When dry, 
they are ready to stain. To obtain a cover-glass 
preparation of blood, cleanse the finger, prick 
the tip, wipe off the first drop of blood that 
exudes, touch the apex of the second drop with a 
cover-glass, spread in the manner described, and 
dry in air. 
Injection Masses.-On account of improvements 
which have been made in general pathologic 
technic within recent years, injections are not so 
essential as they were formerly, and are not gener- 
ally used. If the specimen is well stained, the 
vessel and vessel walls are sufficiently prominent 
to be studied without being injected. 
There are two kinds of injection masses-(1) 
cold and (2) hot. If the hot method is used, the 
fluid is injected into the tissue heated to the 
same temperature as the injection mass. The 
instruments are a syringe with various sized can- 
nulas. Blood-vessels should first be washed out 
with normal salt solution. 
Cold Injection Mass: 
Soluble Berlin blue, 1 
Water, 20. 
Warm Injection Mass (Carmin Gelatin).-The 
warm injection mass is better to use. Place 2 to 2.5 
grams of best carmin in about 15 c.c. of water con- 
taining enough ammonium hydroxid to dissolve 
it. Filter and place over a water-bath, and add 
a concentrated solution of gelatin, stirring con- 
stantly. Gradually add acetic acid until a bright 
red shade is produced. Care must be exercised in 
order to prevent too much acid from being used, 
otherwise the mass will become worthless, owing 
to the precipitation of carmin. 
Fixing Reagents.-These reagents are used for the 
purpose of preserving intact the tissues, cells, and 
especially the nuclei. When the fresh specimen 
is obtained, it is immediately placed in the fixing 
reagent and afterward embedded and stained. 
A good fixative penetrates and kills tissues quickly, 
preserving the tissue elements. The choice of a 
proper fixing reagent for a given tissue depends 
largely on the nature of the pathologic lesions 
PATHOLOGIC TECHNIC PATHOLOGIC TECHNIC 
PATHOLOGIC TECHNIC 
present or suspected, and upon the object for 
which the tissue is preserved. For bacteriologic 
study of tissues, and for many valuable and chemic 
reactions, alcohol is best as a fixative reagent. 
For finer histologic work Zenker's or Orth's fluid 
is to be preferred. Flemming's solution is recom- 
mended for renal tissue when there is fatty degen- 
eration. Tissues fixed in alcohol or in a solution 
of formaldehyd may remain as long as desired. 
Tissues hardened in most of the other fixatives 
must be transferred, after thorough washing in 
water, to alcohol for preservation. It is best 
to pass the specimen successively through alcohol 
of different strengths, as 30, 60, 90, and 96 percent, 
allowing it to remain from a few hours to a day in 
each strength. For general purposes the specimen 
may be transferred from water to alcohol of 70 to 80 
percent, in which it may remain until it is desired 
to embed it. 
Alcohol is used in the laboratory in 95 to 96 
percent strength. The exposed surface of the 
tissues become shrunken and extremely hard when 
placed in alcohol. Tissue to be placed in either 
absolute or 95 percent alcohol should be cut into 
thin sections, 1/2 cm. thick. The volume of 
alcohol to be used should be 15 to 20 times as 
great as the specimen, and it should be changed 
after 3 or 4 hours. The tissue should be kept in 
the upper part of the alcohol by means of absor- 
bent cotton, or the jar may frequently be inverted 
and the alcohol thus kept of even strength. 
For general purposes it is best to place tissues 
at first into 80 percent alcohol, which should be 
replaced in 2 to 4 hours by 95 percent alcohol. 
In this way less shrinkage is caused and the sur- 
face of the tissues is not made so hard. 
Zenker's Fluid: 
1$. Potassium bichromate, 2.5 gm. 
Sodium sulphate, 1 gm. 
Mercuric chlorid, 5 gm. 
Glacial acetic acid, 5 c.c. 
Water, enough to make 100 c.c. 
This solution is practically Muller's fluid, 
saturated with mercuric chlorid and 5 percent of 
glacial acetic acid. 
On account of the evaporation of the acid, it 
is probably best not to add all the acetic acid to 
the stock solution, but only in the proper propor- 
tion to the part selected for hardening. 
Directions for Use.-(1) Fix the tissues in the 
solution for from 1 to 24 or 48 hours, according to 
thickness; (2) wash in running water 12 to 24 
hours; (3) preserve in 80 percent alcohol until used. 
Zenker's fluid penetrates quickly so that tissues 
do not require to be so thin as in the case of other 
fixatives. They should not, however, exceed 1/2 
cm. in thickness. Occasionally there is a precipi- 
tation of mercury, which may be removed by 
adding a small quantity of tincture of iodin (up to 
1/2 of 1 percent) to the alcohol in which the speci- 
mens are preserved. As soon as the color of the 
iodin disappears on account of its forming a 
colorless soluble compound with mercury, more 
iodin must be added, until the alcohol remains 
stained faintly yellow. Tissues hardened in 
Zenker's fluid stain best with alum hematoxylin. 
Good results are also obtained with eosin, followed 
by Unna's alkaline methylene-blue solution. 
Fuchsin and safranin stains are also useful. 
Nuclear figures, red blood-corpuscles, and proto- 
plasm are all preserved by this fixative method. 
Orth's Fluid: 
1$. Potassium bichromate, 2 to 2.5 gm. 
Sodium sulphate, 1 gm. 
Water, 100 c.c. 
Formaldehyd (40 per- 
cent solution), 10 c.c. 
The formaldehyd should be added only at the 
time of using, otherwise the solution will become 
darker in 2 days, and a crystalline deposit will 
occur. The tissue should not be over 1 cm. in 
thickness. The specimens should be washed 
thoroughly in running water for from 6 to 24 hours, 
and then placed in 80 percent alcohol. 
Mercuric Chlorid.-Use a saturated solution 
(made by heat) in normal salt solution. The 
addition of 5 percent of glacial acetic acid is some- 
times advisable. (1) Harden thin pieces of tissue 
(2 to 5 mm. in size) for 1 to 6 hours; (2) wash in 
running water for 24 hours; (3) preserve in 80 
percent alcohol. Tissues fixed by this method 
may be stained by nearly all solutions. With the 
Heidenhain-Biondi triple stain it yields good 
results. 
Muller's Fluid: 
I). Potassium bichromate, 2 to 2.5 gm. 
Sodium sulphate, 1 gm. 
Water, 100 c.c. 
Harden the tissues for from 6 to 8 weeks. 
Change the fluid daily during the first week; once 
a week thereafter. Ordinary tissues are then 
washed in running water overnight before being 
placed in alcohol. Nervous tissue is transferred 
directly from the fluid to the alcohol. This fluid 
hardens tissues slowly without shrinkage, but is 
a poor nuclear fixative and is gradually being 
displaced by more rapid methods. 
Formalin.-The gas, formaldehyd (H.COH), is 
soluble in water to the extent of 40 percent forma- 
lin). The best strength of formaldehyd to use for 
fixing tissues is a 4 percent solution-that is, 10 
parts of the aqueous 40 percent solution (formalin) 
to 90 parts of water-or, better, normal salt 
solution. 
Sections of ordinary tissues not over 1 cm. thick 
are hardened in 24 hours. They may then be 
transferred to alcohol or may remain indefinitely 
in the forma in solution. Thin pieces are suffi- 
ciently hardened in 3 hours, when they may be 
frozen and cut, washed in water, then in alcohol, 
and stained. 
Chromic Acid.-Used in aqueous or alcoholic 
solution in strengths varying from 0.1 to 2 per- 
cent. Weaker solutions are used for nerve tissue. 
Wash out several hours in running water. If the 
object is preserved in alcohol, it must be protected PATHOLOGIC TECHNIC 
PATHOLOGIC TECHNIC 
from the light, or a precipitate will be thrown down 
on its surface. The brownish-green color of 
objects fixed in chromic acid may be removed by 
treating them with hydrogen dioxid. A 0.02 per- 
cent solution is recommended for macerating nerve 
tissue and nonstriated muscle tissue, a cube of 
5 mm. requiring about 24 hours' immersion in 
10 c.c. of the medium. 
Flemming's Fluid (first formula): 
Chromic acid, 0.2 gm. 
Glacial acetic acid, 0.1 c.c. 
Water, 100 c.c. 
This is especially recommended for fixing the 
achromatic spindle-fibers in nuclei. 
Second formula: 
One percent chromic acid, 45 c.c. 
Two percent osmic acid, 12 c.c. 
Glacial acetic acid, 3 c.c. 
This fixes small pieces (2 to 3 mm. thick) in from 
a few to 24 hours, and is useful for fixing the 
figures in cell-division and for many other pur- 
poses. 
solution of the acid to be used than would other- 
wise be possible. The solution is prepared by 
dissolving 1 gram of phloroglucin in 10 c.c. of 
nitric acid. Solution takes place quickly, with 
the generation of considerable heat. The fluid is 
reddish-brown at first, but becomes yellow in the 
course of 24 hours. Dilute with 100 c.c. of a 10 
percent solution of nitric acid. This gives nearly 
a 20 percent solution of nitric acid. The process 
of decalcification in this fluid is extremely rapid- 
a few hours only, as a rule, are required. 
Picric Acid.-A saturated aqueous solution con- 
taining an excess of crystals is sometimes used for 
decalcifying. It has no injurious action on tissues, 
but is extremely slow, frequently requiring months. 
Fresh tissues may be placed directly in the solu- 
tion, which hardens and decalcifies at the same 
time. Instead of being washed out in water, in 
which they would macerate, the pieces of tissue 
are placed directly in 70 percent alcohol to remove 
the acid. 
Embedding Processes. 
Sections may be cut by means of the razor or 
Microtome (g. v.). Two substances are now 
principally used for embedding: they are celloidin 
and paraffin. Celloidin methods are preferred 
for general pathologic work and for histologic 
work, while paraffin sections should be reserved 
for the finest details or for the study of special 
tissues. 
If large sections are desired, celloidin is prefer- 
able; if small sections are desired, paraffin is used. 
Embedding in Celloidin.-Allow the section to 
macerate from 24 hours to several days in 2 
different solutions of celloidin. The two solutions 
are spoken of as thin and thick solutions. To 
make a thick celloidin, 30 grams of the dry celloidin 
are dissolved in 500 c.c. of a mixture of equal 
parts of ether and absolute or 95 percent alcohol. 
This gives a 6 percent solution. 
Diluted with an equal amount of ether and 
alcohol solution, it forms thin celloidin. 
The steps of the embedding process are as follows 
(Mallory and Wright): Pieces of tissue which have 
been properly fixed and finally preserved in 80 
percent alcohol are first to be cut with great 
care. They should rarely be over 4 to 8 mm. thick; 
for most purposes 2 mm. will be sufficient. Pieces 
of this thickness will furnish several hundred 
sections, will embed more quickly than larger 
masses, and will be more rigid when mounted on 
a block. They should never be broader or longer 
than is necessary to show the whole of the process 
under study. Very thin celloidin sections cannot 
usually be obtained with tissues over 1 1/2 or 2 
cm. square, and smaller dimensions are preferable. 
Beginners usually embed larger pieces than are 
necessary. 
The trimmed pieces of tissue are first hardened 
and dehydrated for 24 hours in 95 percent alcohol; 
then macerated in equal parts of alcohol and ether 
for the same length of time, to prepare them for the 
thin celloidin. In the latter they remain at least 
24 hours, preferably for a number of days if at all 
thick, for in this solution occurs most of the in- 
A weaker solution is also used: 
One percent osmic 
acid, 
Glacial acetic acid, 
each, 10 c.c. 
One percent chromic acid, 25 c.c. 
Water, 100 c.c. 
The second formula is the one generally known 
as Flemming's fluid. 
Decalcification. 
Tissues to be decalcified should be cut into thin 
slices of proper sizes (from 2 to 3 mm. thick), for 
embedding in celloidin. Softer tissues need not be 
thinner than 4 to 6 mm. 
Steps in Decalcifying.-(1) The tissues must be 
thoroughly hardened, the three most useful re- 
agents being alcohol and Zenker's and Orth's 
fluids. After using either of the two last reagents, 
the tissues must be washed thoroughly in water 
and placed in alcohol for at least 24 hours. They 
will then be ready for decalcification. (2) The 
decalcifying fluid should be used in large amounts, 
and, if necessary, be frequently changed. (3) 
After decalcification the tissues are to be thoroughly 
washed in running water for 24 hours, to elimi- 
nate every trace of the acid. (4) The tissues 
finally must be hardened again in alcohol. 
The principal decalcifying agents are nitric acid, 
hydrochloric acid, chromic acid, and picric acid. 
Directions for Using Nitric Acid.-(1) Decalcify 
in large quantities of a 5 percent aqueous solution 
of nitric acid, changing the solution every day for 
1 to 4 days. (2) Wash for 24 hours in running 
water, to remove every trace of the acid. (3) 
Harden in 80 percent and then 95 percent 
alcohol. Embed in celloidin. 
Phloroglucin and Nitric Acid.-Phloroglucin is 
not a decalcifying agent, but is added to nitric 
acid to protect the tissues, while allowing a stronger PATHOLOGIC TECHNIC 
PATHOLOGIC TECHNIC 
filtration with celloidin. Finally, the pieces are 
macerated 24 hours or more in thick celloidin. 
They are then mounted on blocks of vulcanized 
fiber, exposed to the air for 2 or 3 minutes until 
the surface hardens a little, and placed in 80 per- 
cent alcohol for 6 to 24 hours to allow the celloidin 
to harden. 
Summary of the Different Steps in Celloidin 
Method.-(1) Place in 95 percent or absolute alco- 
hol for 24 hours; (2) then in ether and 95 percent 
or absolute alcohol (equal parts) for 24 hours; (3) 
in thin celloidin for from 24 hours to 1 or more 
weeks; (4) in thick celloidin for from 24 hours to 
1 or more weeks; (5) mount on blocks of vulcan 
ized fiber; dry for 1 or 2 minutes in the air; (6) 
harden the celloidin in 80 percent alcohol for from 
6 to 24 hours. 
In cutting, the microtome knife should be held 
very obliquely, and covered with 80 percent alcohol. 
Celloidin sections may be stained by nearly all 
methods without removing the celloidin. It can 
be removed, however, by placing the sections in 
absolute alcohol, in oil of cloves, or in equal parts 
of alcohol and ether for 5 to 10 minutes, then 
passing the sections back through absolute into 
ordinary alcohol. 
To Transfer Sections to the Slide.-Transfer the 
section from water to a slide and dry with cloth 
and press down firmly with filter-paper or blotting 
paper before it becomes dry. It may also be 
transferred in the following manner: Place in 
95 percent alcohol and transfer to the slide; at the 
same time allow the vapor of ether to soften the 
section, when it may be smoothly fixed to the 
slide; wash with 80 percent alcohol to harden the 
celloidin. 
Embedding in Paraffin.-This method is very 
useful, especially when thin sections are desired. 
The pieces of tissue should be small, soft, and of 
uniform consistency. In pathologic work it is 
better to cut the sections and to stain them after 
they are fastened to the slide than to stain in 
the mass beforehand, because a variety of stains 
may be used, which is a distinct advantage. The 
first step in the preparation of hardened tissues for 
the paraffin bath is to cut them into small, thin, 
square or rectangular pieces not over 1 cm. 
square, preferably not over 2 to 3 mm. thick. The 
pieces of tissue are then thoroughly dehydrated 
by macerating first in 95 percent and then in ab- 
solute alcohol. From alcohol they are put in some 
substance, such as chloroform or oil of cedar, 
which has the property of mixing with alcohol and 
of dissolving paraffin. From chloroform they 
are transferred to a saturated solution of paraffin 
in chloroform, and then passed through 2 or 3 
separate baths of the melted paraffin to get rid 
of every trace of chloroform. If oil of cedar is 
used, the specimens are transferred directly from 
it into the melted paraffin. 
Summary of Different Steps in Paraffin Method. 
3. Chloroform, 
4. Chloroform satur- 
ated with paraffin, 
5. Paraffin bath, 3 
changes, 
6. Embed and cool 
quickly in cold water. 
6 to 24 hours. 
6 to 24 hours. 
1 to 6 hours. 
Method No.2 
1. Ninety-five percent 
alcohol, 
2. Absolute alcohol, 
3. Oil of cedar, 2 
changes, 
4. Paraffin, 3 changes, 
until no odor of oil of 
cedar, 
5. Embed and cool 
quickly in cold water. 
6 to 24 hours. 
6 to 24 hours. 
6 to 24 hours. 
2 to 8 hours. 
In the second method instead of oil of cedar, 
xylol, equal parts of oil of cloves and turpentine, 
or oil of cloves and xylol may be used. 
For embedding the specimens, metallic boxes, 
or paper boxes made of stiff writing-paper, may 
be used. Melted paraffin is poured into the paper 
box to the depth of about 1 cm. The pieces of 
tissue are placed in the box with that side down 
from which sections are preferred. Several pieces 
of tissue are thus placed in the melted paraffin 
when the box is placed upon cold water. After the 
paraffin has hardened, the paper is removed, and 
the paraffin is divided up according to the pieces 
in it. 
One of the blocks is fastened to the object- 
holder by heating the latter in a flame until it 
will just melt the paraffin when the block is held 
in proper position against it. The holder is then 
quickly cooled in cold water. Trim off the over- 
lying paraffin until the specimen is reached, and 
adjust in the paraffin microtome. To get the 
best specimens the temperature of the room must 
be so regulated that the sections are ribbon- 
shaped. 
The sections are laid on the surface of a large 
dish of warm water, about 44° C., and, if necessary, 
gently stretched so as to remove wrinkles. Paint 
the surface of a slide with a thin layer of Mayer's 
glycerin albumin mixture (equal parts of white 
of egg and glycerin); wipe off excess with a towel 
so that a faint layer is left; dip the slide under the 
sections; arrange them in order; lift the slide, and 
drain off the water. The slide is then placed in a 
slanting position until dry, when it is put in the 
thermostat for from 2 to 12 hours at a temperature 
of 54° to 60° C. To get rid of the paraffin in the 
sections they are treated with 2 or 3 changes of 
xylol, and then with absolute alcohol, followed 
by 95 percent alcohol. 
If the celloidin and oil of cloves mixture is used, 
the paraffin is removed by means of xylol, followed 
by oil of origanum or oil of bergamot, and finally 
by 95 percent alcohol, because absolute alcohol 
will dissolve the celloidin (Mallory and Wright). 
Serial Sections by the Celloidin Method.-The 
specimen is embedded, mounted on vulcanized 
Method No. i. 
1. Ninety-five percent 
alcohol, 
2. Absolute alcohol, 
6 to 24 hours. 
6 to 24 hours. PATHOLOGIC TECHNIC 
PATHOLOGIC TECHNIC 
fiber, and hardened in 80 percent alcohol. Mois- 
ten the knife of the microtome with 95 percent 
alcohol. As the sections are cut they are drawn 
upon the surface of the knife and arranged in the 
proper order by means of a camel's-hair brush. 
Place the slide against the back of the knife and 
transfer the section by means of the camel's-hair 
brush. The section is then fastened to the slide 
by allowing a few drops of ether to be poured upon 
it, after which all the edges are smoothed down 
very carefully. The slides are then numbered, 
and may be kept in a jar of 80 percent alcohol. 
Serial Sections by the Paraffin Method.-Cut 
ribbons a yard long, if necessary, and place them 
on sheets of paper in proper order. They may 
then be divided into short series with a needle, 
and fastened to the slide by means of Mayer's 
albumin mixture. 
cent alcohol or absolute alcohol should be kept in 
stock to be used in making other solutions. This 
can be used as a stain by adding 1 part to 9 parts 
of water. 
Loeffler's Alkaline Methylene-blue Solution : 
Saturated alcoholic solution 
of methylene-blue, 30 c.c. 
Solution of caustic potash in 
water (1:10,000), 100 c.c. 
This solution keeps well for long periods of time. 
Gabbett's Methylene-blue Solution : 
Methylene-blue, 2 
Sulphuric acid, 25 
Water, 75. 
Used as a decolorizer and contrast stain for 
tubercle bacilli. 
Fuchsin.-A saturated alcoholic solution to be 
kept in stock. See Fuchsin. 
Ziehl-Neelsen's Carbol-fuchsin: 
Saturated alcoholic solution 
of fuchsin, 10 c.c. 
Five percent carbolic acid 
water, 90 c.c. 
This solution stains quickly and keeps well. 
Gentian-violet.-A saturated alcoholic solution; 
should be kept in stock. 
Ehrlich's Anilin Gentian-violet Solution : 
Saturated alcoholic solution 
of gentian-violet, 16 c.c. 
Anilin water, 84 c.c. 
Mix and let stand for 24 hours. Does not keep 
longer than 1 week or 10 days. 
Safranin.-Any of the three following solutions 
may be used: 
1. A saturated aqueous solution of safranin O, 
soluble in water (to be made with aid of heat). 
2. A mixture of equal parts of a saturated 
aqueous solution of safranin O, soluble in water, 
and a saturated alcoholic solution of safranin, 
soluble in alcohol. 
3. Two percent anilin water, 100 
Safranin O, soluble in water, in 
excess. 
Saturate the solution with heat (60° to 80° C.), 
and filter. 
Methyl-violet.-Aqueous solutions of several 
strengths, as 0.5 to 2 percent. Stains nuclei of 
cells, bacteria, etc. 
Eosin.-Stains rapidly and gives a beautiful, dif- 
fuse, rosy hue. It is one of the best contrast stains 
with hematoxylin. Make a 5 percent aqueous 
solution, and dilute as required. It is also a 
specific stain for red blood-corpuscles (to which it 
gives a copper color), for certain leukocytes, and 
for the giant-cells of leprosy and tubercle. 
Eosin-hematoxylin stain and the "polychrome" 
methylene-blue, eosin solution (Romanowsky stain) 
Staining Solutions. 
Aqueous Alum-hematoxylin Solution : 
Hematoxylin in crystals, 1 
Saturated aqueous solution of 
ammonium-alum, 100 
Water, 300 
Thymol, a crystal. 
Dissolve the hematoxylin in a small quantity of 
hot water. The combined solution is then exposed 
to light in a bottle tightly stoppered with a plug of 
cotton. The solution will be ready for use in 
about 10 days, after which time it should be kept in 
a tightly stoppered bottle. It is very easily pre- 
pared and gives excellent results. 
Delafield's Hematoxylin: 
Hematoxylin in crystals, 4 gm. 
Alcohol, 95 percent, 25 c.c. 
Saturated aqueous solution 
of ammonium-alum, 400 c.c. 
Add the hematoxylin dissolved in the alcohol to 
the alum solution, and expose the mixture in an 
unstoppered bottle to the light and air for 3 or 4 
days. Filter, and add- 
Glycerin, 100 c.c. 
Alcohol, 95 percent, 100 c.c. 
Allow the solution to stand in the light until the 
color is sufficiently dark, then filter and keep in a 
tightly stoppered bottle. The solution keeps well 
and is very powerful. So long as it is good, the 
solution has a purplish tinge. 
Alum-carmin: 
Carmin, 2 gm. 
Alum, 5 gm. 
Water, 100 c.c. 
Boil 20 minutes, adding enough water to make 
up for that lost in evaporation. When cool, filter 
and add a crystal of thymol to prevent the growth 
of mold. 
Methylene-blue.-A saturated solution in 95 per- PATHOLOGIC TECHNIC 
PATHOLOGIC TECHNIC 
are excellent for routine work. The former 
combined with Wright's stain is in conjunction 
especially valuable in the study of nuclear struc- 
tures. The Romanowsky stain is particularly 
serviceable in examining the malarial organism 
and other parasites. 
Ehrlich-Biondi-Heidenhain Triple Stain.-To 
100 c.c. of a saturated aqueous solution of orange 
add, with continual agitation, 20 c.c. of a saturated 
aqueous solution of acid fuchsin and 50 c.c. of a 
like solution of methyl-green; dilute with from 60 
to 100 volumes of water. A drop on blotting 
paper should form a spot bluish-green in the 
center, orange at the periphery; a red zone outside 
the orange indicates that the mixture contains too 
much fuchsin. From 6 to 24 hours are required to 
stain. Wash out in alcohol and clear in xylol. 
Chromatic elements are colored blue; cytoplasm, 
violet or orange-red; karyoplasm the same, but in 
lighter tones, and all the denser protoplasmic ele- 
ments the same, but darker (Gilson). This is the 
best stain for photomicrography, except for con- 
nective tissue (Lindsay Johnson). A slightly 
acid reaction of the alcohol used for washing out 
will produce a relatively strong coloration by 
the methyl-green; while that by the fuchsin will 
be relatively pale; the opposite result will be ob- 
tained if the alcohol contains a trace of alkali. 
The addition of very dilute acetic acid, until the 
red tint is markedly intensified, will restore the 
energy of the fuchsin, which is likely to decline 
after a time (Heidenhain). 
Wright's Stain.-A modification of Jenner's 
stain, an alkaline eosinate of methylene-blue. 
To a 1/2 percent aqueous solution of sodium 
bicarbonate in an Erlenmeyer flask is added 
1 percent of Griibler's medicinal methylene-blue. 
The mixture is placed in steam sterilizer for an 
hour. When cooled to it is added with constant 
stirring a 1 to 1000 aqueous solution of Griibler's 
water-soluble yellow eosin till the original color 
changes from blue to purple and forms a yellowish 
scum on the surface. The resulting precipitate 
upon filtration is dried and added to methyl 
alcohol (3/10 gram will require 100 c.c. for solu- 
tion). The solution is filtered and to the filtrate 
is added 25 percent of methyl alcohol. 
Giemsa Stain.-The formula is as follows: 
Azure II, 3 grams; eosin B. A., 0.8 gram; glycerin 
(C. P.), 250 c.c.; methyl alcohol (C. P.), 250 c.c. 
The films are fixed in methyl alcohol and then 
stained 5 minutes in a mixture of 14 drops of the 
stain to 10 c.c. of distilled water. A trace of 
sodium carbonate added to the water accentuates 
the basic stains. Then wash, dry and mount. 
Pianese Double Stain.-Prepare a saturated solu- 
tion of nigrosin in a saturated alcoholic solution of 
picric acid; mix 2 volumes of this with 1 volume of 
anilin water, and evaporate in open air. The 
crystals deposited are dissolved in absolute alcohol, 
and from this solution green crystals are obtained, 
soluble in alcohol, ether, and water. For tissues, 
make a 2 percent solution in alcohol; for micro- 
organisms, in water. Stain sections first in 
lithium carmin, treat with acid alcohol, wash, and 
immerse in an alcoholic solution of picronigrosin 
until they assume a brown hue. Decolorize in 
oxalic acid. Nuclei are stained red; plasma dark 
yellow; cartilage yellow; connective tissue pale 
green; elastic fibers violet. 
Silver Nitrate.-Particularly adapted to the 
study of epithelial and connective tissues. Make 
a 1 percent solution in distilled water, and dilute 
from 2 to 4 times for use. Very thin sections of 
fresh tissue are washed in distilled water to re- 
move the chlorids, immersed for 1/2 hour in the 
solution in the dark, washed in distilled water, 
and then placed in water and exposed to sunlight 
until brown. Fix in a solution of sodium hypo- 
sulphite in the dark, and mount in glycerin jelly. 
Gold Chlorid.-Recommended for tracing nerve- 
endings in fresh tissues, and for staining connec- 
tive tissue and cartilage cells. Place small pieces 
of tissue, 1/4 inch square, in from a 0.5 to a 1 per- 
cent solution of commercial gold chlorid in dis- 
tilled water. Keep in the dark, and when the 
tissue has become yellow, wash in distilled water. 
Then expose to the light in 50 c.c. of water con- 
taining 2 drops of acetic acid for 48 hours, or until 
the tissue acquires a purple tint. 
Osmic Acid.-Tissues fixed in osmic acid and 
subsequently treated with weak pyrogallic acid 
are stained greenish-black (Lee). It is a fixing 
reagent as well as a stain for fat or myelin. A 
1 or 2 percent solution is used. A developing 
mixture of water, alcohol, tannin, and pyrogallic 
acid, or a 5 percent solution of tannin is used by 
Kolosson. Treatment with oxalic acid 1 part, 
in water 15 parts, gives a Burgundy-red stain to 
osmium objects, which should be washed in water 
before they are put into the acid. 
Clearing Reagents.-These reagents are used 
for the purpose of rendering certain tissue ele- 
ments more distinct. For this purpose acetic acid 
may be recommended in the strength of 2 to 5 
parts of acid to 100 parts of water. 
This reagent causes swelling of the ground 
substance, and facilitates the study of the nuclei, 
elastic fibers, fat, myelin, and microorganisms. 
Other reagents are also used for the purpose of 
clearing tissues, but care must be exercised to 
select one which will not dissolve the anilin dye 
in the section already stained, and one which will 
clear it when celloidin is used. When either the 
celloidin or paraffin method is used, one of the 
following clearing reagents is recommended: oil 
of bergamot, or a mixture of oil of cloves 1 part, 
and oil of thyme 4 parts. When anilin dyes have 
been used, the best clearing reagent is xylol. It 
is to be preferred also in unembedded sections, 
and for paraffin sections that have been dehy- 
drated in absolute alcohol. Other reagents are 
oil of lavender, oil of cedar, and anilin oil. 
Mounting Reagents.-The best mounting re- 
agent is Canada balsam, although dammar and 
colophonium are sometimes used. 
Staining Methods.-Tissues are stained for the 
purpose of differentiating the tissue elements; to 
show bacteria; to present evidences of pathologic 
change in the arrangement of the tissues, and to 
show the affinity of tissue for special anilin dyes. 
The three principal tissue elements are (1) the PATHOLOGIC TECHNIC 
PATHOLOGIC TECHNIC 
cell, (2) intercellular substance, and (3) patho- 
logic products. 
The cell contains the nucleus, protoplasm, and 
cuticle. Within the nucleus may be seen the 
nucleolus, resting nucleus, and frequently bacteria. 
The protoplasm may show the centrosome and 
polar bodies, the different varieties of granules, 
dendritic processes of ganglion cells, axis-cylinder 
and terminal processes, contractile elements of 
striated muscle-fiber, red blood-globules, cilia of 
bacteria. Within the cuticle there may be seen 
certain dots in ependymal cells, cilia in certain 
renal cells, and bile capillaries. 
In the intercellular substance may be studied the 
cement substance of endothelial cells; the ground 
substance of connective tissue; connective-tissue 
fibrilte; myxomatous tissue; mucin; elastic 
fibers; intercellular substances of cartilage; ground 
substance of bone; myelin; neuroglia fibers; clubs 
of actinomyces, and capsules of bacteria. 
Pathologic products may be shown after the stain- 
ing process: as, for instance, the hyalin substance 
may be changed into substances such as fibrin, 
mucin, amyloid glycogen, hyalin colloid, kerato- 
hyalin, and eleidin. There may also be present 
fat, hemosiderin, hematoidin, or hemoglobin. 
The tissue elements may be stained differentially 
in a number of ways, frequently one stain answer- 
ing the purpose, while in others a series of stains 
may be required, depending upon the affinity of 
certain chemic constituents of the cell for certain 
dyes. 
Nuclear Stains.-Probably the most serviceable 
stain for nuclei in general work is alum-hema- 
toxylon, using eosin as a contrast stain. Such 
carmin stains as lithium carmin, followed by 
picric acid, have also been used. 
Safranin is also highly recommended as a nuclear 
stain. Other nuclear stains are eosin, followed by 
methylene-blue, and Unna's alkaline solution of 
methylene-blue (methylene-blue, 1 part; potassium 
carbonate, 1 part; water, 100 parts). 
Method.-(1) Stain for from 2 to 30 minutes; 
(2) wash in several changes of water; then leave 
the sections, if possible, for several hours or over- 
night in a large dish of water; (3) contrast stain 
usually an aqueous solution of eosin, 1/10 tol 1/2 
of 1 percent, for 1 to 5 minutes; (4) alcoho, 95 
percent, 2 or 3 changes to dehydrate and remove 
excess of contrast stain; (5) clear in oleum origani 
cretici, or in the mixture of oil of cloves and thyme; 
(6) mount in Canada balsam. 
To Study Changes of Karyomitosis.-In studying 
these changes it is essential that the tissue be 
selected and fixed in one of the reagents at the 
earliest possible moment after its removal. For 
this reason the figures produced by mitosis cannot 
be so well studied when removed postmortem. 
A fixing reagent should be selected which pene- 
trates quickly, such as safranin. 
To Stain Karyokinetic Figures.-Fix the section 
in Zenker's or Orth's fluid, embed in paraffin, and 
stain with Babe's anilin safranin solution, pre- 
pared as follows: Two percent anilin water, 100; 
safranin O, soluble in water in excess. Saturate 
the solution by heating in a flask placed in hot 
water at a temperature of 60° to 80° C., and 
filter. 
Method.-(1) Stain the paraffin section from a 
few minutes to an hour; (2) wash in water; (3) 
wash in 95 percent alcohol, to which are added a 
few drops of acid alcohol (hydrochloric acid, 1 c.c.; 
70 percent alcohol, 99 c.c.); (4) wash in pure 
95 percent alcohol, followed by absolute alcohol; 
(5) clear with xylol; (6) mount in xylol balsam 
(Canada balsam, 4 grams; xylol, a sufficient 
quantity to make a fluid having a syrupy consis- 
tency). 
If the specimen is embedded in celloidin, clear 
the section in oil of bergamot or oleum origani 
cretici after the 95 percent alcohol, wash in xylol, 
and mount in xylol balsam. 
Carbol-fuchsin and anilin gentian-violet may 
also be used in the place of safranin. 
Staining of Bacteria in Tissues.-After embed- 
ding the section in the usual manner-by the 
paraffin method preferably-it is cut in a very 
thin section and attached to a slide by means of 
Mayer's glycerin-albumin mixture (equal parts 
of white of egg and glycerin). The best staining 
fluids are dilute aqueous or alcoholic solution of 
the anilin dyes, such as methylene-blue, gentian- 
violet, and fuchsin. 
The sections should be heated moderately while 
being stained, either in a thermostat or over an 
alcohol lamp. 
The decolorizing agent will vary with the stain 
employed. Those generally used are dilute acetic 
acid, 1 : 100 up to 1 : 1000, alcohol, iodin in potas- 
sium iodid solution, dilute mineral acids, chlorid 
of anilin, anilin, and ethereal oils. 
Many pathogenic microorganisms require special 
staining fluids for their detection in the tissues, for 
further discussion of which see under their special 
heads, as Gonococcus, Pneumonia, Typhoid 
Fever, etc. 
Gram's Method.-Heat 2 to 5 minutes, or stain 
cold 20 to 30 minutes (tubercle bacilli, 12 to 24 
hours), in saturated solution of gentian-violet 
anilin-water; rinse quickly in absolute alcohol; 
transfer to Gram's solution (1 to 1 1/2 minutes), in 
which the specimen turns black; wash in alcohol 
until the black color vanishes and a pale gray color 
appears; dry and mount in Canada balsam. The 
decolorization may be hastened by adding 3 percent 
nitric acid to the alcohol and then washing in pure 
alcohol. All the tissue cells are decolorized by this 
method, while the bacteria are stained a deep blue. 
The cells may subsequently be stained with a 
watery or alcoholic solution of Bismarck brown 
2 to 5 minutes, then washed in absolute alcohol 
until the section is yellowish-brown. This method 
is of diagnostic value, as certain bacteria are 
stained, others decolorized, by it. 
Bacteria that are Stained by Gram's Method.- 
Staphylococcus pyogenes aureus; streptococcus 
pyogenes; micrococcus lanceolatus (of pneumonia); 
micrococcus tetragenus; bacillus of diphtheria; 
bacillus of tuberculosis; bacillus of leprosy; bacillus 
of anthrax; bacillus of tetanus; bacillus aerogenes 
capsulatus; ray fungus of actinomycosis. 
Of these the tubercle bacillus and the bacillus PATHOLOGIC TECHNIC 
PEDICULOSIS 
of leprosy require a much longer exposure to the 
stain than other bacteria in the list. 
Bacteria that are not Stained by Gram's Method.- 
Gonococcus; diplococcus intracellularis meningit- 
idis, micrococcus melitensis; bacillus of chancroids 
(Ducrey); bacillus of dysentery (Shiga); bacillus of 
typhoid fever; bacillus coli communis; bacillus 
pyocyaneus; bacillus of influenza; bacillus of 
bubonic plague; bacillus of glanders (bacillus 
mallei); bacillus of Friedlander; bacillus proteus; 
spirillum of Asiatic cholera; spirillum of relapsing 
fever. 
Staining of Nervous Tissue.-The tissue elements 
to be studied in this structure are: (1) The gang- 
lion cells, including the dendritic and axis-cylinder 
processes; (2) the myelin sheaths, and (3) the 
neuralgia fibers. Each requires special fixing 
reagents to be studied in detail. Formaldehyd 
(4 percent) has, however, been recommended as a 
fixing reagent for the preservation of all of these 
elements of nerve tissue. 
Special stains are also required for each element: 
thus for the ganglion cells, Nissl's and Lenhossek's 
methods have been used. 
For staining the dendritic and axis-cylinder pro- 
cesses, Golgi's slow or quick method is recom- 
mended. 
For staining the myelin sheath, use Weigert's 
quick method or Pal's modification of Weigert's 
process. 
F or staining neuroglia fibers, use Weigert's or 
Mallory's method. 
All of these processes are quite complicated and 
require very accurate manipulation in order to get 
the best results. 
Transmission of Materials Containing Bacteria, 
in the Mails.-The ruling of the Post-Office Depart- 
ment of the U. S. is as follows: 
That the order of the Postmaster General of 
December 27, 1897 (Order No. 677), amending 
Order No. 88 of February 5, 1896, prescribing the 
conditions under which specimens of diseased 
tissues may be admitted to the mails is hereby 
further modified in the following manner: 
Specimens of diseased tissues may be admitted 
to the mail for transmission to the United States, 
State, or municipal laboratories, only when en- 
closed in mailing packages constructed in accord- 
ance with the specifications hereinafter enume- 
rated: Liquid cultures, or cultures of micro- 
organisms in media that are fluid at the ordinary 
temperature (below 45° C. or 113° F.) are unmail- 
able. . Such specimens may be sent in media that 
remain solid at ordinary temperatures. 
Upon the outside of every package shall be 
written or printed the words 'Specimen for Bac- 
teriological Examination. This package to be 
treated as letter mail.' No package containing 
diseased tissue shall be delivered to any repre- 
sentative of any of said laboratories until a permit 
shall have first been issued by the Postmaster 
General certifying that said institution has been 
found to be entitled, in accordance with the 
requirements of this regulation, to receive such 
specimens." 
The regulation includes not only cultures, but 
"specimens of diseased tissues." The specifica- 
tions prescribing the manner of packing, which are 
minute and complicated, may be obtained from 
local postmasters. 
PEDICULOSIS (Lousiness; Phthiriasis).-A con- 
tagious animal parasitic disease, characterized by 
the presence of pediculi, hemorrhagic points, and 
scratch-marks. 
Varieties.-There are three varieties: (1) Pedicu- 
losis capitis; (2) pediculosis corporis; (3) pedicu- 
losis pubis. 
Pediculosis Capitis.-Pediculosis capitis is 
due to the invasion of the scalp by the 
pediculus capitis, or head-louse. It is character- 
ized by severe itching, which excites scratching 
and leads to the formation of excoriations with 
serous, purulent, or sanguineous exudation. This 
dries in the form of crusts and mats the hair 
together. A foul odor is usually present. Owing 
to the irritation, the postcervical glands may 
become enlarged, and in some cases suppurate. 
The occipital region is the most frequent seat of 
this particular dermatitis. Scattered papules, 
pustules, and excoriations are frequently seen 
about the face and neck. Pediculi are present 
in varying numbers, and ova or "nits" in abund- 
ance. Ova are grayish, translucent, pyriform 
bodies, attached to the hair by a membranous 
sheath, they hatch out in from 3 to 8 days. 
Pediculosis capitis is far more common in children 
than in adults. 
Diagnosis.-Owing to the presence of the pedi- 
culi and the "nits," the diagnosis is, as a rule, easy. 
Every pustular eczema in the occipital region 
should be regarded with suspicion, and warrants a 
search for pediculi and ova. 
Treatment.-The object of treatment is to kill 
the pediculi, devitalize the ova, and subdue the 
accompanying inflammation. Among the most 
popular and efficacious remedies are petroleum, 
either pure or with equal parts of olive oil, and 
balsam of Peru. They should be thoroughly 
applied to the scalp for 1 or 2 nights, followed in 
the morning by a shampoo of the scalp with soap 
and water or tincture of green soap. Other 
remedies, such as cocculus indicus, staphisagria 
(2 fluidrams to 4 fluidounces dilute acetic acid), 
or corrosive sublimate (1 to 4 grains to 1 fluid- 
ounce), may be employed. 
When there are much pustulation and crusting, 
the following ointment may be applied: 
I|. Ammoniated mercury, gr. xxx 
Petrolatum, 3 j. 
For the removal of "nits," alkaline solutions 
(such as carbonate of sodium, borax, etc.) or acid 
solutions (dilute acetic acid) should be applied 
frequently. There is rarely need of sacrificing the 
hair in women, although this may be done in 
children. 
Pediculosis Corporis.-This is produced by the 
pediculus corporis or vestimenti, a parasite larger 
than the scalp louse. It resides in the seams of 
the underclothing, where the ova are deposited. 
They hatch out in about 6 days. The louse is PEDICULOSIS 
PELLAGRA 
merely present upon the skin when foraging. The 
perambulation of the parasite produces intense 
itching, which gives rise to violent scratching. As 
a result linear scratch-marks, blood crusts, and, 
in chronic cases, pigmentation and thickening may 
be seen. The parts affected are those coming in 
contact with the seams of the undergarments- 
namely, the scapular region, the chest, waist, and 
thighs. Hemorrhagic points mark the sites 
from which pediculi have extracted blood. The 
disease is common among the poorer classes in 
adults of middle or advanced age. It is rare in 
children. 
Diagnosis.-The characteristic features are the 
presence of excoriations, nail-marks, blood crusts, 
and hemorrhagic points upon the scapular 
region and around the waist. Careful search in 
the seams of the undergarments will usually reveal 
the existence of pediculi.- 
rare cases the beard, eyebrows, or eyelashes. The 
disease is almost exclusively observed in adults, 
and is usually contracted during sexual intercourse. 
Diagnosis.-The diagnostic features are itching 
about the genitalia and the presence of pediculi 
and ova. 
Treatment.-The parts should be washed with 
soap and water twice daily. Lotions, being more 
cleanly than ointments, are preferable. Corrosive 
sublimate, the tincture of cocculus indicus, or 
the fluidextract of staphisagria are all excellent 
applications. 
I). Fluidextract of staphisagria, 5 ij 
Dilute acetic acid, 3 iij 
Distilled water, 3 iij. 
White precipitate ointment (1 dram to 1 ounce), 
or mercurial ointment, is effective. Vinegar, 
dilute acetic acid, and soda and borax solutions 
1. Head Louse. 2. Body Louse. 3. Crab Louse 4. Bed Bug. 
5. Mexican Bed Bug.-(Stitt.) 
Treatment.-The most important part of the 
treatment is the sterilization of the clothes and 
bed-linen. These should be thoroughly boiled or 
baked. A lotion of carbolic acid or thymol will 
relieve the itching quite effectually. When sterili- 
zation of the clothing cannot be carried out, it is 
best to prescribe an ointment of sulphur (1 dram to 
1 ounce) or staphisagria (2 drams to 1 ounce). 
Pediculosis Pubis.-The pediculus pubis, or crab 
louse, is responsible for this form. It is the 
smallest of the pediculi, and is found clinging 
tenaciously to the hair with the head buried in the 
follicular orifice. The "nits" are seen attached to 
the hair-shaft. Itching about the genitalia, vari- 
able in degree, is the most prominent symptom. 
Hemorrhagic points, papules, and excoriations 
may also be present. The pubis and perineum are 
the usual regions involved. Occasionally the 
axillee and sternal regions are attacked, and in 
are of value in effecting the removal of the nits. 
PELIOSIS.-See Purpura. 
PELLAGRA. Synonyms.-M alatie della miseria, 
Mal del sole, Pellarella, Asturian leprosy, Alpine 
scurvy, Mal rosso, Mal del padrone. 
Definition.-Pellagra is a chronic specific disease, 
probably infectious, characterized locally by 
erythema involving usually the exposed portions 
of the body surface and recurring from year to 
year during the summer months; characterized 
constitutionally by symptoms involving the gastro- 
intestinal tract and the mental and nervous 
systems. 
History and Distribution.-The first authentic 
description of the disease as a distinct entity was 
written by Gaspar Casal, a Spanish physician, his 
monograph on the subject appearing in 1762, after 
his death. The disease was observed by him as 
early as 1735 and was described as "Mal de la rosa." PELLAGRA 
PELLAGRA 
His description of the disease was based on clinical 
observations among the peasants of the Asturias 
(Oviedo, Spain). In Italy, the first recorded 
reports appeared in 1700 (Ramazini) and 1740 
(Pujati), but it was not until 1771 that serious 
attention was directed to the disease through the 
efforts of Frapolli. Though these are the first 
recorded reports of the disease, Sambon adduces 
abundant evidence in support of the supposition 
that the disease existed in Italy for several 
centuries prior to this time. 
In Italy, the disease has always been most 
prevalent in the North-Piedmonte, Lombardia, 
Veneto-sweeping from the Julian Alps to the 
Piedmont Alps and from Lago Maggiore down- 
ward to the Arno. Within recent years, however, 
with betterment in general conditions, with the 
tremendous growth in industrial concerns, and 
with the extensive temporary emigration during 
the summer months, the disease has practically 
disappeared in Piedmont, and is rapidly decreasing 
in Lombardy and certain sections of the region of 
Venice. 
The disease is extending to the south of Italy, 
and is to be found in Umbria, Tuscany, the Marche 
and the Abruzzi. In 1881, the number of pellag- 
rins reported from Lombardy was 36,630. In 
the 1905 census this number had decreased to 
15,746. In Umbria, Tuscany and the Marche, the 
official figures show an increase: 
and 150 cases in 1910, and the disease is reported 
from other middle western states and California. 
Etiology.-The specific agent producing pellagra 
is unknown. During the past century many 
theories have been advanced, among them the 
following: Insufficient nutriment, insolation, 
syphilis, poverty, insanitary surroundings, leprosy, 
alcohol, molds, bacteria, metazoa, maize, proto- 
zoa, etc. 
All theories concerning etiology except the 
bacterial, maize, metazoal and protozoal may be 
dismissed as unworthy of comment. 
Bacterial Theory.-Tizzoni has recently an- 
nounced the isolation of a specific bacterium as 
the causative agent-namely, the streptobacillus 
pellagras. Nichols and Siler failed to confirm this 
observation, notwithstanding the fact that they 
repeatedly attempted to cultivate microorganisms 
from the blood, spinal fluid and body organs, on 
various kinds of culture media. Many other 
observers in different sections of the United 
States have reported like results. 
It has been suggested that the specific bacterium 
is present in the intestinal canal. This theory 
should be regarded with skepticism, as it is ex- 
tremely difficult to harmonize with it the clinical 
picture of the disease, some peculiarities in its 
topographic distribution and more particularly 
some striking facts as to transmissibility. Should 
the specific agent prove to be an intestinal bacter- 
ium, the method of transmission is probably by 
water or by contact. During the summers of 1909 
and 1910, Siler studied pellagra in an institution 
averaging more than 2000 patients, 350 of whom 
were pellagrins. Notwithstanding the facts that 
all patients and the large force of employees used 
the same water and that the nurses were thrown in 
intimate contact with the patients, not one case 
of pellagra developed in any of the attendants. 
This has been the experience of Italian investi- 
gators and, with one exception, also of investi- 
gators in the United States. 
Maize Theory.-This theory which has been 
advanced so positively by continental authorities, 
particularly Italian and Roumanian, assigns to 
Indian corn, of one sort or another, the role of 
principal etiologic factor. Adherents of this 
theory disagree as to just how and why corn 
products produce the disease. 
1. Sound Corn.-It is asserted by one group of 
investigators that sound corn produces the disease, 
but opinions differ as to the actual exciting factor. 
Briefly, the following views are held: (a) Deficient 
nourishment with particular reference to nitrogen 
starvation in those subsisting, mainly, on a corn 
diet, (b) Toxic substances of various kinds, for 
example, toxins normally present in corn, toxins 
generated by the action of intestinal bacteria after 
the ingestion of corn. 
2. Damaged Corn.-Another group asserts that 
damaged corn is the factor of principal import. 
Here, again, opinions differ, the following views 
being held: (a) Specific toxins are generated dur- 
ing the decomposition of corn, (b) Poisons are 
generated during the period of germination, (c) 
A specific poison is produced through the action 
1881 
1905 
Tuscany, 
924 
1137 
Marche, 
406 
1436 
Umbria, 
872 
4250 
The disease is quite common in Spain, Portugal, 
the Tyrol, Austria-Hungary, Roumania, Servia, 
Bulgaria, and Asia-Minor; it has also been observed 
in India. Sandwith has reported its extensive 
prevalence in Egypt, and it occurrence in Southern 
Africa. On the Western Hemisphere it is to be 
found in North, Central and South America, 
Barbados, Jamaica and Porto Rico. 
Though isolated cases were reported in the 
United States by Gray and Tyler in 1864, Sher- 
well 1883, Harris 1902 and Sherwell 1902, no wide- 
spread interest was manifested in the disease until 
1907, at which time Searcy, of Alabama, and 
Babcock, of South Carolina, reported independ- 
ently extensive outbreaks in institutions for the 
insane in Alabama and South Carolina. Since 
1907 a rapidly increasing interest in the subject 
has been evinced and to-day-1911-the disease 
is reported from more than twenty states. Un- 
fortunately, in many of the states in which the dis- 
ease is most prevalent, there are no facilities for 
the determination of accurate statistics as to inci- 
dence and no accurate estimate can be made as to 
the prevalence of the disease. Could accurate 
statistic be obtained, there can be no doubt that 
the figures would show not less than 10,000 cases 
in the United States in 1910. The disease is most 
prevalent in the Southern United States-North 
and South Carolina, Tennessee, Georgia, Florida, 
Alabama, Mississippi, Louisiana. Siler saw in the 
State of Illinois approximately 200 cases in 1909 PELLAGRA 
PELLAGRA 
of Penicillium glaucum on corn, (d) Toxins are 
generated by the action on corn of certain fungi- 
namely, aspergillus fumigatus and aspergillus 
flavescens. 
Italian investigators hold corn products respon- 
sible in great part on the following hypotheses: 
Pellagra followed the introduction of maize into 
Italy, and the extension of the disease was coin- 
cident with increase in area of corn cultivation. 
The disease occurs exclusively among people who 
subsist mainly on corn products and in districts in 
which corn is either cultivated or into which it is 
imported. 
The Italians claim to have greatly reduced 
incidence and mortality rates in the endemic 
areas, by inspection of corn with condemnation 
and exchange of damaged lots; by the installation 
of drying apparatus; by the provision of proper 
baking ovens; by the compulsory notification of 
pellagrins to the health authorities; by supplying 
to all pellagrins corn-free meals twice each year 
for periods of not less than 40 days; by the issue 
of free salt to pellagrins and by the establishment 
of special hospitals-" Pellagrosarii "-for the 
treatment of this disease. 
In 1905, Sambon suggested that corn was not the 
agent producing the disease; and in 1910 he 
further elaborated his hypothesis after an investi- 
gation of conditions in Italy. His investigations 
tend to refute all theories alleging a relationship 
between corn per se and pellagra. 
In this connection it should be stated that 
Italians seem to have lost sight of pellagra in 
their investigations and have confined their 
researches almost exclusively to corn. 
Sambon has presented quite conclusive evidence, 
that though pellagra was first described in Italy 
about the middle of the eighteenth century, it 
must have existed centuries prior to that time and 
has no coincident relationship with the introduc- 
tion of corn from America; nor is there any definite 
proof to substantiate the supposition that corn 
was introduced into Europe from America. 
The topographic distribution of pellagra does 
not coincide with that of corn cultivation and corn 
consumption. In Italy the disease is confined 
largely to endemic foci, and though corn is culti- 
vated throughout certain provinces and the diet of 
the peasants throughout such districts consists 
almost exclusively of corn-"polenta"-it by no 
means follows that pellagra will be observed 
throughout such districts; on the contrary, the 
disease is frequently sharply limited to restricted 
areas. 
The disease in Italy is almost, without exception, 
confined to the field laborer and is never found in 
cities, notwithstanding the fact that the peasant 
in cities subsists, in large measure, on "polenta." 
The disease has practically disappeared in certain 
provinces and shows marked decrease in others. 
The claims put forward by Italian authorities in 
explanation of the decrease in the disease are sub- 
ject to criticism. The laws providing for inspec- 
tion, condemnation, and exchange of corn are in 
numerous instances a "dead letter." The use of 
a drying apparatus for extracting moisture is an 
unpopular measure, and is but seldom applied to 
home grown corn. The lists of cases notified to the 
health authorities as pellagrins are inaccurate and 
contain the names of many patients who are not 
pellagrins, while many actual cases of pellagra are 
not included. It is difficult and beyond reason to 
attribute any permanent or even temporary pro- 
phylactic benefit to the soup kitchen. These 
kitchens are open only for a fortnight in the spring 
and autumn, supply only a midday meal, are fre- 
quented largely by non-pellagrins, and many 
actual cases of pellagra (for various reasons), do 
not attend. The special hospitals for the treat- 
ment of pellagrins are few in number and admis- 
sions are confined largely to children. 
It would seem more reasonable to attribute the 
decrease in the disease in Italy to other factors. 
The disease is intimately associated with field 
labor. In many sections there has been a marked 
increase in industrial pursuits and as the peasant 
changes his occupation from that of a field laborer 
to that of an operative, in silk factories, cotton 
factories or other industrial concerns, the exposure 
to the probable transmitting agent necessarily 
becomes more remote. 
It is also a fact that in many communes numbers 
of the inhabitants emigrate temporarily during the 
summer months to Switzerland, France, Austria, 
and other countries, for the purpose of engaging 
in tunnel and railway construction. 
There can be no doubt that corn is not the etio- 
logic factor in the production of pellagra, and this 
opinion is substantiated by experience with the 
disease in this country. Any one familiar with the 
extensive use of corn products in the Southern 
States, can well understand that the maize theory, 
pending thorough investigation, would be accepted 
as explaining the etiology of pellagra. Corn-meal, 
however, comparatively speaking, plays but an 
insignificant part as an article of diet throughout 
the remainder of the United States. During the 
summer of 1909 Nichols and Siler followed an out- 
break of pellagra in an Illinois institution. The 
disease was apparently endemic, affecting about 
200 of 2000 patients. It was possible to collect 
reliable statistics, covering a period of 4 years, as 
to the amount of corn products consumed. It 
was found that the average amount consumed per 
patient was less than 2 ounces daily and the corn 
products used were always fresh and of excellent 
quality. 
To more thoroughly test the relationship of corn 
products to the disease a feeding experiment was 
instituted at the suggestion of Nichols to be con- 
tinued for a period of 1 year. Two cottages, each 
with a capacity of 60 patients, were filled with 
selected nonpellagrins. In one cottage the diet 
included approximately 16 ounces of corn-food- 
stuffs per day, while in the control cottage a corn- 
free diet was instituted. The patients were care- 
fully observed for a period of 1 year. The results 
reported by Watkins are as follows: 
Patients 
Cases of 
pellagra 
Suspects 
Corn diet, 
59 
4 
1 
Corn-free diet, 
58 
5 
3 PELLAGRA 
The proportion of new cases developing in these 
cottages agrees practically with the percentage of 
new cases developing throughout the institution 
(2000 patients). Corn products were eliminated 
from the general diet of the institution in the 
summer of 1909. 
Nichols has carried out extensive experimental 
inoculations on animals-rabbits and guinea-pigs 
-using extracts of cultures of various molds and 
bacteria grown on corn. His results were negative. 
An attempt has been made to transmit the dis- 
ease to animals-monkeys. No definite results 
have been obtained. 
Metazoal Theory.-Quite recently-May, 1910- 
Prof. Alessandrini, of Italy, has recorded the find- 
ing of a nematode (Filaria ?) as yet unclassified, in 
the skin of pellagrins and in the drinking water of 
endemic areas, to which he assigns etiologic sig- 
nificance. But other observers have failed to 
confirm this observation. 
Long has recently (1910) suggested, as a work- 
ing "hypothesis," that the entamebse together with 
the inflammatory changes brought about by their 
action are the etiologic factors of importance. 
Nichols and Siler in 1909 directed attention to 
the strikingly large percentage of pellagrins pre- 
senting evidence of entamebic infection and were 
impressed with the fact that this infection was not 
an etiologic, but an important complicating and 
possibly predisposing factor. 
Protozoal Theory.-In 1905 Sambon suggested 
that the disease is parasitic (protozoal) and in 1910 
reiterated this opinion and further elaborated it by 
assuming that the disease is not only parasitic, but 
insect-borne and conveyed by some species of 
simulium (sand-fly). He bases his theory on the 
following facts: (1) The disease is parasitic for 
the reasons that: (a) the cutaneous and other 
symptoms usually recur periodically each spring 
for many years even though the patients remove 
from an endemic area and subsist on a corn-free 
diet; (b) its peculiarities in distribution, symp- 
toms, chronicity and pathology correspond to 
those of other protozoal diseases (trypanosomiasis, 
kala-azar, syphilis). (2) The disease is insect- 
borne because: (a) it is not directly contagious; 
(b) infection through food or water does not ex- 
plain its epidemiology; (c) it is limited to rural 
districts, being practically restricted to the field 
laborer. (3) The disease is conveyed by simulium, 
because: (a) the topographic distribution of the 
simulium and pellagra appear to be coincident; 
(b) the adult stage of the simulium apparently 
presents a seasonal incidence similar to pellagra; 
(c) the insect is found in rural districts only, but 
seldom entering houses or towns; (d) the only class 
of people constantly exposed to the bite of the 
simulium are field laborers; (e) the disease is 
practically confined to the field laborer, and (f) 
other similarly small blood-sucking flies are 
strongly suspected of being conveyors of disease- 
phlebotomus, papatassi, dilophus febrilis. 
It seems quite likely that eventually the disease 
will be placed among those of parasitic origin, 
probably protozoal. 
Clinical Description.-In attempting to outline 
the clinical picture of this disease, one is confronted 
by a multitudinous variety of symptoms enumer- 
ated by various authorities as making up the 
symptom-complex. Many of these symptoms, 
when analyzed, can definitely be ascribed to com- 
plicating factors and are of no diagnostic value in 
pellagra per se. The disease, under ordinary cir- 
cumstances, is chronic, extending over a period of 
many years-about 4 to 25 or more. The incu- 
bation period is unknown. The disease is not 
hereditary. 
An acute typhoidal type of the disease, of sudden 
onset and rapid course, usually ending in death, is 
referred to by many authorities. As such cases, 
however, are of rare occurrence and likely to be 
confounded with an exacerbation of a chronic 
condition, they do not merit classification as a 
distinct type. 
The symptoms are cutaneous-involving more 
particularly the extensor surfaces; and consti- 
tutional-involving the gastrointestinal tract and 
nervous system. Prodromal symptoms-general 
malaise, vertigo, digestive disturbance, obscure 
epigastric pain and various other symptoms-are 
referred to by many authorities, but these symp- 
toms are so indefinite in character and so incon- 
stant in occurrence as to preclude reliable deduc- 
tions for diagnostic purposes. 
Cutaneous Symptoms.-The skin symptoms are 
by far the most striking, most constant, most 
characteristic and most important from a diagnos- 
tic standpoint. In their absence, a diagnosis 
of pellagra is unwarranted. 
The eruption usually appears suddenly as an 
erythema, irregular in outline, involving most 
frequently the dorsal aspect of the hands. Its 
most characteristic feature is the symmetry of 
PELLAGRA 
Showing Edema of Hands. Bleb Formation Occurred, 
and Illustration Shows Condition after Blebs have 
Ruptured.-{Reproduced by courtesy of Dr. George A. Zeller.) 
the lesions on both hands. The erythema may 
be confined to the dorsum of the hands, or extend 
downward to the finger-nails or upward on the 
forearm. Quite frequently it encircles the wrist 
as a more or less broad cuff and the exact similarity 
of the bands on both wrists constitutes a striking 
picture. The erythema, while most commonly 
observed on the dorsum of the hands, is by no 
means confined to this area. It is of frequent 
occurrence on the face, usually as symmetrical 
patches on the cheeks or forehead. Occasionally 
the entire face is involved-"pellagra mask"; PELLAGRA 
PELLAGRA 
this has been observed in Italy but not (by 
Nichols and Siler) in the United States. The neck 
is frequently involved, the erythema appearing in 
symmetrical patches or occasionally encircling the 
neck as a broad or narrow band-"Casal's collar." 
Eventually the skin becomes pigmented and 
thickened, and as the erythema recurs from year 
to year this pigmentation is accentuated. After 
repeated recurrence of the erythema, atrophy of 
the skin occurs. The elbows and knees occasion- 
ally show evidence of erythema-pigmented, 
roughened, thickened skin. The genitalia are 
occasionally involved. Palmar involvement has 
been recorded by many observers. In observa- 
tions covering several hundred cases in the United 
States and Italy, Siler saw this in only one case in 
which a complicating factor could not be excluded. 
Pain is but seldom complained of in the sites of 
erythema, though a burning sensation may be 
present. 
The erythema appears during the spring, 
summer, or autumn, more commonly spring and 
autumn. The exact time of its appearance 
depends largely on climatic conditions; being 
hastened by warmth, sunlight and settled weather 
Showing Erythematous Cuff around Both Wrists 
and Slight Extension to Palm over Thenar Eminence. 
-(Reproduced by courtesy of Dr George A. Zeller.) 
Triangular tongues of erythema, base above, are 
occasionally observed extending from the neck 
downward, in front or behind, depending greatly 
on the type of clothing worn. It not infrequently 
appears on the dorsum of the feet and as bands 
encircling the legs, particularly so if no shoes are 
worn. Occasionally reddish-brown patches, re- 
sembling hemorrhagic areas, appear on the upper 
and lower lids. The erythema in the early stages 
may easily be mistaken for a sunburn of moderate 
severity in mild cases. It may be differentiated 
by the fact that the sunburn clears up within 
3 or 4 days, while the pellagrous erythema pursues 
a different course. 
The color, at onset, depends largely on the type 
of patient affected. In blondes the color is first a 
bright pink, in brunettes usually a dull red. As 
the erythema progresses, the affected areas gradu- 
ally take on a darker shade and within a few days 
show a characteristic purplish, dusky red color. 
In brunettes, the lesions are occasionally of a dark, 
greenish-bronze cast. At the onset of the ery- 
thema the color disappears on pressure, but later 
the contrary is the case. The line of demarcation 
between healthy skin and affected areas is usually 
distinct and clear cut. Ordinarily, the color 
begins to fade after about 10 days, and desqua- 
mation occurs. The exfoliation of epidermis may 
occur in fine scales or in large bran-like flakes. 
After desquamation is practically complete the 
skin is soft, smooth and pinkish in color, a distinct 
line of partially desquamated epithelium being 
noteworthy around the edges, showing distinctly 
the extent of the lesion. The entire course of the 
erythema and subsequent desquamation may 
occur within a period of a few days, but it usually 
lasts for a period of 3 or 4 weeks, or even longer. 
In some cases, edema of the affected area may be 
observed and occasionally vesicles appear. These 
vesicles frequently become confluent and may 
become infected. Nichols and Siler found the 
bleb formation to be a symptom of serious omen, 
and to bear an important relationship to prog- 
nosis. 
Pellagrous Erythema, Involving the Face and Neck. 
Desquamation Taking Place.-(.Reproduced by^courtesy of 
Dr. George A. Zeller.) 
conditions; and retarded by cold, rainy unsettled 
weather. Though the erythema may occur with- 
out exposure to sunlight, it is an undoubted fact 
that direct exposure to the sun's rays markedly 
accentuates the condition. During the winter it 
disappears. 
Constitutional Symptoms.-Gastrointestinal PELLAGRA 
PELLAGRA 
symptoms may or may not be present. Some 
writers go so far as to attribute important diag- 
nostic significance to the appearance of the 
tongue and to a special odor noted in the diarrheic 
stools. Siler concludes that in some instances 
there are no gastrointestinal symptoms; while 
in many others these disturbances may be attri- 
buted to complicating factors, most frequently 
amebic dysentery. This complication has been 
referred to also by many observers in the southern 
sections of the United States, notably Allen and 
Long. 
Among other complicating factors may be 
mentioned bacillary dysentery and various pro- 
of these symptoms is distinctive of pellagra and 
may be accounted for by complicating factors 
(amebic and bacillary dysentery, etc.). 
In the more severe manifestations of the disease 
the picture is characteristic, and it is evident that 
some specific agent is at work in addition to a 
complicating dysentery or other factor. The 
tongue is edematous and red; the buccal mucosa 
is intensely inflamed and dotted with ulcerating 
patches, and the gums are soft and spongy. There 
is swelling of the salivary glands accompanied by 
excessive salivation. The mouth symptoms may 
be so severe in character as to cause very intense 
pain, prevent protrusion of the tongue and inter- 
Note Symmetrical Erythematous Involvement of Hands, Forearms and Neck.-{Reproduced by courtesy of 
Dr George A. Zeller). 
tozoal and zoo-parasitic intestinal parasites 
(flagellates and cihates, uncinaria, ascaris, trich- 
uris, schistosomidse, etc.). In the absence of clear 
and definite cutaneous symptoms, it is inadvisable 
to attribute any great diagnostic importance to 
gastrointestinal disturbances. 
Bearing in mind the fact that the digestive dis- 
orders may be due in large part to a complicating 
factor, they may be briefly summarized in the 
following manner: The patient may suffer from 
dyspeptic symptoms, as evidenced by coated 
tongue, poor appetite and flatulency. Frequently 
there is redness of the tongue with exfoliation of 
epithelium, giving rise to so-called "bald" tongue. 
The digestive disturbances may be accompanied 
by a mild transient diarrhea, by diarrhea of a 
more stubborn type or by severe dysentric 
symptoms-frequent small stools containing blood 
and mucus and of a highly offensive odor. None 
fere greatly with eating and drinking. The dysen- 
teric symptoms in such cases are most pro- 
nounced and intractable. The gastrointestinal 
symptoms may precede, accompany or follow the 
cutaneous manifestations. Vomiting is seldom 
noted and vertigo is uncommon. 
Nervous and Mental Symptoms.-Symptoms 
referable to the nervous system may or may not 
exist, depending partly on the stage of the disease. 
Ordinarily during the first 3 or 4 years, nervous 
symptoms are indefinite in character and fre- 
quently absent. During the periodical recurrences 
there may be in the early stages mental depression, 
insomnia, irritability, headache, vertigo, tremors, 
languor and exaggeration of reflexes. 
Complications in pellagra-(uncinariasis, ame- 
bic and bacillary dysenteries, tuberculosis, syphilis, 
bilharziosis)-are so frquent and the mental symp- 
toms observed differ so markedly in character as PELLAGRA 
PELLAGRA 
to make it impossible to define with any degree of 
accuracy the .nervous symptoms referable to 
pellagra. 
As the disease progresses a small percentage of 
cases manifest involvement of the nervous system 
and some develop the so-called " pellagrous 
insanity." It is said that 10 percent of pellagrins 
in Italy develop this type of mental derangement. 
In the later stages the mental depression fre- 
quently develops into profound melancholia with 
eventual terminal dementia. There may be 
periods of excitability alternating with stupidity, 
hallucinations, delusions of persecution and 
suicidal tendencies. Suicide by drowning is 
reported as common; but of the thousands of cases 
of pellagra in the United States, Siler was able to 
find only one instance in which this tendency was 
exhibited. The reflexes are said to be diminished 
or absent in the later stages; but in a series of 100 
cases Siler found the contrary to be true, both the 
patellar and plantar reflexes being increased in a 
majority of cases. The Babinski reflex is some- 
times present. 
The facies in pellagra-a fixed, despondent 
appearance-is said to be typical, but in many 
cases this has not been confirmed. The final 
picture resembles closely that of general paralysis 
of the insane. Sandwith attributes diagnostic 
value to tenderness on pressure along the sides of 
the dorsal vertebrae (4th to 9th). 
Differential Diagnosis.-In the presence of 
cutaneous lesions, it is quite unlikely that pellagra 
will be mistaken for other diseases. Sprue gives 
rise to somewhat similar mouth conditions, but 
the characteristic copious, whitish diarrheic stools, 
with no history of cutaneous lesions, will serve to 
differentiate. It has been compared to leprosy, 
but it is inconceivable that the two diseases can be 
confounded. Weeping eczema on the dorsum of 
the hands differs from pellagra in many respects- 
irregular outline of affected areas, peculiar color, 
itching, persistent serous oozing on stimulation. 
Both in the United States and Italy, vitiligo is 
mistaken for a pellagrous eruption; but scaling is 
not present in vitiligo. 
Pathology.-The disease presents no uniform 
definite pathologic findings. Abnormal conditions 
observed can, in many cases, be attributed to 
complicating factors. 
The blood, in uncomplicated cases, shows slight 
decrease in red cells and hemoglobin, and a relative 
increase in the mononuclear elements with slight 
leukocytosis. The anemia in uncomplicated cases 
is of low grade. Blood platelets are found in 
excessive numbers. Though prolonged and care- 
ful search has been made of both unstained and 
stained blood preparations, with one or two excep- 
tions all observers have failed to demonstrate any 
bacterial or protozoal organisms. TheWassermann 
and Noguchi modification complement fixation 
reactions are negative in uncomplicated cases. A 
specific complement fixation reaction has been 
obtained by the use of liver from pellagrins as 
antigen. 
The cutano-reaction with extracts of all grades of 
corn has been worked out by Hirshfelder with 
negative results. Stained preparations from the 
spinal fluid, liver and spleen show no organisms. 
There is decrease or absence of hydrochloric acid 
secretion in the stomach. 
Necropsies frequently show serious concurrent 
diseases. Atrophy of the muscles, heart, liver and 
small intestines is found. The spleen is fre- 
quently small in size and shows atrophic changes. 
The large intestine frequently shows numerous 
undermined ulcers of the amebic type or well 
marked folliculitis. Various intestinal parasites 
may be present. The nervous system may show 
no pathologic change. 
In chronic cases there may be diffuse leptomen- 
ingitis with scattered thickened areas, degeneration 
of the nerve elements with round celled perivas- 
cular infiltration, and an excess of fluid in the ven- 
tricles. The spinal cord frequently shows sclerosis 
of the posteromedian and posterolateral columns. 
Harris has observed in chronic cases atrophy of 
the pancreas, softening of the cord, and degenera- 
tive changes in the myelin sheaths of nerves and of 
nerve cells of the gray matter and ganglia. 
Prognosis.-In determining mortality rates in 
this disease, complicating diseases must be con- 
sidered. Experience shows that, on necropsy, 
sufficient cause for death is revealed in many 
cases, exclusive of pellagra. 
The death rate shows wide variation from year 
to year. It may occasionally rise to 25 percent, 
but usually is from 5 to 10 percent. 
The disease occasionally results in death during 
the first attack. Ordinarily its course is extremely 
chronic-persisting for from 5, 10, 20, 30 or even 
40 years, frequently without apparent detriment 
to the patient. 
Entire recovery is not infrequent, but at least 
2 or 3 years should elapse, without symptoms, 
before cure is pronounced. 
Treatment.-At the present time, with our vague 
ideas as to the etiology of the disease, no satis- 
factory line of treatment can be formulated. 
The most rational procedure would seem to be 
symptomatic. In a general way improvement in 
hygienic surroundings and more liberal diet, with 
particular attention to the proteid constituents, are 
indicated. 
Should complicating factors be present-amebic 
or bacillary dysentery, ciliate or flagellate diar- 
rheas, bilharziosis, ascaris, trichuris or uncinaria 
infections-the treatment should be directed 
toward the eradication of these factors. 
Cutaneous manifestations but seldom require 
treatment. Should local dressings be applied a 
protective dressing of borated zinc oxid ointment 
is appropriate. When erythematous areas become 
infected a wet dressing of some mild antiseptic- 
boric acid-is indicated. 
Arsenic may be used internally-Fowler's 
solution or atoxyl. Should atoxyl be administered 
it should be exhibited in small doses by hypodermic 
injection-20 to 30 drops of a 10 percent solution 
every second or third day. 
Nichols has used Ehrlich's "606" in one case 
without noteworthy immediate effect. It has been 
suggested by Bass that change of climate will bring PELLETIERIN TANNATE 
PELVIS, DEFORMITIES 
about improvement. Direct transfusion of blood 
may be resorted to in extremely severe and hopeless 
cases. 
Prophylaxis.-As our knowledge of the etiology 
of the disease is so indefinite, it is manifestly 
impossible to formulate any measures for prophy- 
laxis. 
PELLETIERIN TANNATE.-A mixture of the 
tannates of 4 alkaloids obtained from pomegranate; 
it is an effective teniafuge. Dose, 3 to 8 grains, in 
powder, taken fasting, and followed after 20 
minutes by a full dose of castor oil. Pelletierin is 
actively poisonous, causing weakness of the legs. 
It is best administered in the form of Tanret's 
pelletierin, each bottle of which contains an adult 
dose. But the practitioner had better not pre- 
scribe this for poor people, as each dose costs three 
dollars] See Anthelmintics. 
PELLITORY.-See Pyrethrum. 
PELVIC INFLAMMATION.-See Puerperal 
Fever. 
PELVIMETRY.-The process of determining the 
size of the pelvis. 
It is by no means desirable to subject every 
pregnant woman to the annoyance of a careful 
pelvic measurement. In private practice those 
patients should be measured who give a history of 
difficulty in former labors, or who are subjects of 
evident deformity, such as rachitis or kyphosis. 
An accurate determination of the size of the 
pelvis necessitates both internal and external 
measurements. These measurements are made 
between certain well-defined bony prominences. 
Pelvic Diameters.-The most important are the 
following: Anteroposterior (of pelvic inlet), that 
which joins the sacrovertebral angle and the pubic 
symphysis. Anteroposterior (of pelvic outlet), see 
upon one side to the junction of the ischiopubic 
rami on the opposite side. Sacropubic, see 
Anteroposterior. Sacrosubpubic, see Con- 
jugate, Diagonal. Sacrosuprapubic, that con- 
necting the sacro vertebral angle and the upper por- 
tion of the symphysis pubis. Transverse (of 
pelvic inlet), that connecting the two most-widely 
separated points of the pelvic inlet. Transverse 
(of pelvic outlet), that connecting the ischial 
tuberosities. 
Size of the Pelvic Inlet.-Its transverse diameters 
are obtained by measuring between the anterior 
superior spinous processes of the ilia (26 cm.); 
between the widest divergence of the crests of the 
ilia (29 cm.), and between the two femoral 
trochanters (31 cm.). 
The anteroposterior or conjugate diameter is 
obtained by measuring between the depression 
under the last lumbar vertebra and the upper edge 
of the symphysis (20 1/4 cm.). This is called the 
external conjugate diameter. A more reliable 
measurement is the internal conjugate diagonal. 
This is the measurement between the promontory 
of the sacrum and the middle of the subpubic liga- 
ment. It is obtained by passing the index and 
middle fingers of the left hand into the vagina in 
such a manner that the tip of the middle finger 
rests upon the top of the promontory of the 
sacrum. A mark is made on the upper surface of 
the hand, just where it presses against the under 
surface of the symphysis. The distance between 
this mark and the tip of the middle finger is the 
internal conjugate diagonal (12 3/4 cm.). The 
true conjugate is obtained from this diameter by 
simply subtracting 13/4 cm. 
Size of the Pelvic Cavity.-This is determined 
approximately by a vaginal examination. Thus, 
a tumor obstructing the pelvic canal could easily 
be discovered in this way. 
Size of the Pelvic Outlet.-This is rarely de- 
creased except in kyphosis, when it is the trans- 
verse diameter that suffers. This diameter is 
measured between the two tuberosites of the ischia 
(11 cm.). 
TABLE OF MEASUREMENT OF THE FEMALE PELVIS 
COVERED WITH THE SOFT PARTS. 
Between iliac spines, 
26 
cm. 
Between iliac crests, 
29 
cm. 
External conjugate diameter, 
20} 
cm. 
Internal conjugate diagonal, 
12} 
cm. 
True conjugate, estimated, 
11 
cm 
Right diagonal, 
22 
cm. 
Left diagonal, 
22 
cm. 
Between trochanters, 
31 
cm. 
Circumference of pelvis, 
90 
cm. 
Schultze's Pelvimeter. 
Coccypubic. Coccypubic, that which joins the 
tip of the coccyx with the subpubic ligament; the 
anteroposterior diameter of the pelvic outlet. 
Conjugate, the anteroposterior diameter of the 
pelvic inlet. Conjugate, diagonal, that connecting 
the sacrovertebral angle and subpubic ligament. 
Conjugate, external, that connecting the spine of 
the first sacral vertebra and the middle of the upper 
border of the symphysis pubis. Conjugate, true, 
that connecting the sacrovertebral angle and the 
most prominent portion of the posterior aspect 
of the symphysis pubis. Oblique (of pelvic inlet), 
left and right, that connecting one sacroiliac 
symphysis with the opposite iliopectineal eminence. 
Oblique (of pelvic outlet), that extending from the 
middle of the under surface of the sciatic ligament 
PELVIS, DEFORMITIES.-The pelvis is divided 
into two parts by the iliopectineal Une. The 
shallow, expanded portion situated above this 
line is known as the false pelvis. It has very little 
influence on the course of labor. 
The narrow, more contracted portion situated 
below the iliopectineal line is called the true pelvis. 
Contraction or deformity of this part of the pelvis 
may cause serious difficulty during childbirth. 
The shape of the pelvic inlet or superior strait 
is usually cordiform, the pelvic cavity is irregularly 
circular, and the outlet or inferior strait is cordi- PELVIS, DEFORMITIES 
PELVIS, DEFORMITIES 
form. The pelvic cavity is lined with muscles, 
the most important of which is the iliopsoas. 
These muscles serve as cushions or protectors to 
the bony wall during labor, and also guide the 
presenting part in the most favorable direction 
for its expulsion. The pelvic floor, which almost 
completely closes the pelvic outlet, is formed 
chiefly by the levator ani muscle. This muscle, 
by the direction of its resistance, directs the pre- 
senting part upward and outward under the 
symphysis pubis. 
For the measurements of the normal pelvis, see 
Pelvimetry. 
The frequency of pelvic deformity is about 14 
percent. It is probable, however, that in not more 
than 5 percent is the deformity severe enough to 
seriously complicate labor. 
The following is the most satisfactory classifica- 
tion of deformities of the female pelvis: 
contraction very rarely exceeds 2 or 3 cm. This 
pelvis is the result of arrested development at an 
early period of life. It has been thought to be due 
to a mild degree of rickets which has passed away 
rapidly, leaving no characteristic deformity. 
The diagnosis of this variety of contracted pelvis 
is easily made by noticing the proportionate de- 
gree of contraction of the different pelvic measure- 
ments. 
The mechanism of labor in the generally equally 
contracted pelvis differs but slightly from the 
normal. Vertical flexion at the inlet is somewhat 
exaggerated, while there is little or no lateral 
flexion. 
The treatment of labor obstructed by this vari- 
ety of pelvis will depend upon the degree of con- 
traction. If the true conjugate diameter measures 
9 1/2 cm. or over, delivery at term with forceps 
should be comparatively easy. With a contrac- 
tion between 8 and 9 1/2 cm., the induction of pre- 
mature labor is advisable. This, supplemented 
by the use of forceps, if necessary, will be found 
almost uniformly successful. When the contrac- 
tion is below 8 cm., choice will have to be made 
between symphysiotomy, cesarean section, and 
craniotomy. 
The simple flat pelvis is one in which there is 
shortening of the anteroposterior diameter, the 
other diameters being normal. The amount of 
contraction very rarely exceeds 3 cm. It may be 
congenital in origin, or it may be caused by carry- 
ing heavy weights during early childhood. In 
this variety of pelvis the external conjugate di- 
ameter will be less than 20 1/4 cm., probably 18, or 
even 17; the true conjugate will be less than 11 
cm., probably as low as 8. The other pelvic 
measurements will practically be normal. 
The rachitic flat pelvis is one of the results of 
infantile rickets. In- this disease there is a diminu- 
tion of the mineral constituents of the bones, which 
results in a preternatural pliability. There is a 
tendency, therefore, to an exaggeration of the 
changes which occur in the development of an 
adult from an infantile pelvis-i. e., there is ex- 
cessive rotation of the sacrum on its transverse 
axis. This results in an abnormal projection of the 
promontory, which causes a decrease in the con- 
jugate diameter, an increase in the curve of the 
sacrum, a decrease in the depth of the pelvis, and 
a widening of the iliac spines and crests. The 
true conjugate diameter may be as low as 4 cm. 
Diagnosis.-This pelvis is recognized by the 
marked decrease in both internal and external 
conjugate diameters; by the disturbance of the 
relation between the iliac spines and crests, the 
distance between the crests being almost or fully 
as great as between the spines; by the marked 
sinking of the depression under the last lumbar 
vertebra, it being now almost on a level with the 
posterior superior iliac spines; and by the ac- 
companying constitutional signs of rickets. 
The mechanism of labor in the simple flat and in 
the rachitic flat pelvis is the same. The long 
diameter of the head engages in the longest diam- 
eter of the pelvis, which is now the transverse; 
there is exaggerated lateral flexion of the head, so 
CLASSIFICATION OF DEFORMITIES OF THE FEMALE 
PELVIS, ACCORDING TO SCHAUTA. 
A. Anomalies of the Pelvis the Result of Faulty 
Development. 
1. Simple flat. 
2. Generally equally contracted (justominor). 
3. Generally contracted flat (nonrachitic). 
4. Narrow funnel-shaped (fetal or undeveloped). 
5. Imperfect development of one lateral mass of the 
sacrum (obliquely contracted or Naegele's pelvis). 
6. Imperfect development of both lateral masses (trans- 
versely contracted or Roberts' pelvis). j 
7. Generally equally enlarged (justomajor or giant pelvis). 
8. Split pelvis. 
B. Anomalies Due to Disease of the Pelvic Bones. 
1. Rachitis. 
2. Osteomalacia. 
3. New growths. 
4. Fractures. 
5. Atrophy, caries, and necrosis. 
C Anomalies in the Conjunction of the Pelvic Bones 
1. Too firm union (synostosis). 
(1) Of symphysis. 
(2) Of one or both sacroiliac synchondroses. 
(3) Of sacrum with coccyx. 
2. Too loose a union or separation of the joints. 
(1) Relaxation and rupture. 
(2) Luxation of the coccyx. 
D. Anomalies Due to Disease of the Superimposed 
Skeleton. 
1. Spondylolisthesis. 
2. Kyphosis. 
3 Scoliosis. 
4. Kyphoscoliosis. 
E. Anomalies Due to Disease of the Subjacent 
Skeleton. 
1. Coxalgia 
2. Luxation of one femur. 
3 Luxation of both femurs. 
4. Unilateral or bilateral club-foot. 
5. Absence or bowing of one or both lower extremities. 
Contracted Pelvis.-Only the commoner vari- 
eties of contracted pelves will be considered. 
These, as found in this country, are: 
1. The generally equally contracted pelvis. 
2. The simple flat pelvis. 
3. The rachitic flat pelvis. 
4. The kyphotic pelvis. 
5. The obliquely contracted pelvis. 
The generally equally contracted pelvis is, as 
its name implies, a pelvis in which there is pro- 
portionate contraction of all its diameters. This PELVIS, DEFORMITIES 
PELVIS, DEFORMITIES 
that it may adapt itself to the increased sacral 
curve; and there is imperfect vertical flexion, so 
that the bitemporal diameter (8 cm.) may first 
be brought in relation with the contracted con- 
jugate instead of the biparietal (9 1/4 cm.). 
labor should be expected, with perhaps mal- 
position of the child or prolapse of the cord. If, 
after waiting a reasonable length of time, the head 
will not engage, version should be performed; if 
the head engages, but further delivery ceases, 
forceps should be employed. 
2. When the true conjugate measures 8 to 9.5 
Female Pelvis, Seen from the Front. 
Infantile Pelvis, Viewed in the Axis of the Brim. 
Female Pelvis Viewed in the Axis of the Brim, Showing 
the Diameters of the Superior Strait. 
Outlet of Pelvis. Anteroposterior and Transverse 
Diameters of Outlet seen from Below. 
Reniform Rachitic Pelvis. 
cm. If the patient is seen in time, labor should be 
induced at the thirty-sixth or thirty-eighth week 
of gestation. If, now, there is difficulty in delivery, 
or if the patient is not seen until term, version or 
forceps, as previously described, will usually 
prove successful. 
3. When the true conjugate measures 6.5 to 8 
c.m. Here one of the graver obstetric operations 
The treatment of labor complicated by a flat 
pelvis depends upon the degree of contraction. 
Four grades are usually recognized: -r 
1. When the true conjugate measures 9.5 to 11 
cm. Here it is advisable to allow the patient to 
proceed to term. A rather prolonged and difficult PELVIS, DEFORMITIES 
PELVIS, DEFORMITIES 
is indicated. Choice must usually be made be- 
tween symphyseotomy, cesarean section, and 
craniotomy. It should be remembered, however, 
compressibility of the child's head and the strength 
of the uterine contractions are factors which must 
not be overlooked in the treatment of a contracted 
pelvis. 
4. When the true conjugate measures less than 
6.5 cm. This is an absolute indication for cesarean 
section, since it would be dangerous to pull even a 
mutilated child through such a degree of contrac- 
tion. 
The kyphotic pelvis is that variety of pelvic de- 
formity resulting from Pott's disease of the lower 
spinal column. In this deformity the promontory 
of the sacrum is pushed backward and the con- 
jugate diameter at the pelvic inlet is slightly in- 
Transversely Contracted Pelvis of Robert 
Oblique Pelvis, from Ankylosis of the Hip-joint and 
Disuse of the Right Leg. 
Rostrated Malacosteon Pelvis in Early Stage of 
Deformity. 
creased. The deformity is most marked at the 
pelvic outlet; the transverse diameter is markedly 
decreased by approximation of the ischial spines, 
and the conjugate diameter is somewhat lessened 
by forward displacement of the coccyx. 
The diagnosis is easily made by the marked de- 
crease in the transverse diameter at the outlet and 
by the associated kyphosis with its characteristic 
signs. 
The mechanism of labor in this variety of pelvic 
deformity may differ but little from the ordinary. 
Oblique Pelvis of Naegele. 
that spontaneous birth may occur even with a 
contraction as low as this, and also that version 
or forceps may prove successful. The size and PELVIS, INJURIES 
PEMPHIGUS 
Posterior rotation is frequent; also, the first stage 
of labor may be precipitate, while the second stage 
is abnormally slow. 
Treatment.-Here, again, the treatment depends 
upon the degree of contraction. If the contraction 
of the transverse diameter is slight-not below 8 
cm.-spontaneous delivery may be expected. 
With a greater degree of contraction than this, 
choice will be made between the induction of pre- 
mature labor, forceps, symphysiotomy, cesarean 
section, and craniotomy. 
The obliquely contracted pelvis is due to a variety 
of causes, such as scoliosis, coxalgia, club-foot, 
the absence of one extremity, and dislocation or 
fracture of one limb. The pelvis becomes obliquely 
contracted from the overuse of one limb, or, in the 
case of the scoliotic pelvis, from unequal pressure 
from above. The diagnosis is easily made by the 
presence of the marked asymmetry of the pelvis, 
associated with one of its various causes. Unless 
the deformity is marked, no treatment is neces- 
sary. Marked degrees of contraction will require 
forceps, version, the induction of premature labor, 
symphyseotomy, cesarean section, or craniotomy. 
PELVIS, INJURIES.-Fracture of the pelvis is 
usually the result of direct violence-a heavy fall, 
a cart-wheel passing over the pelvis, a squeeze 
between the buffers of two railway cars, and simi- 
lar accidents. It may, of course, result from 
gunshot wounds or from indirect violence, as when 
a person falls from a height and alights on his feet. 
The symptoms are inability to walk, though the 
patient may be able to move his limbs in bed; 
mobility and crepitus, obtained by pressing on 
both crests of the ilium; pain on moving or cough- 
ing; displacement, which may be recognized by 
external examination, by the rectum, or by the 
vagina. Inability to empty the bladder or voiding 
of bloody urine denotes some injury of this organ. 
Fracture of the acetabulum is indicated by the 
crepitus elicited on rotating the femur with one 
hand placed over the trochanter. 
Separation of the symphyses, or of the sacro- 
iliac articulation, is recognized by the free mobility 
of the part, and at the same time an interval may 
be felt in the situation of the separation. The 
pelvic viscera are frequently injured in this fracture; 
rupture of the bladder or urethra, giving rise to 
extravasation of urine, laceration of the rectum 
or of the larger blood-vessels, may occur. 
Usually the rami of the pubes and ischium are 
the seats of fracture. The line of fracture may 
pass above the acetabulum in various directions, 
or it may involve the acetabulum, fissuring its 
floor or fracturing its margin. The acetabulum 
may be comminuted, and the head of the femur 
driven into the pelvic cavity. Any portion of 
these bones may be broken, including the crest of 
the ilium or the tuberosity of the ischium, and not 
infrequently both innominate bones. 
Treatment.-Absolute rest of from 6 weeks to 2 
months is essential. The pelvis must be bound 
around with a broad roller-bandage, and the pa- 
tient laid to rest on a flat bed or mattress. The 
thighs must be flexed upon the abdomen and 
supplied with pillows under the knees. 
Fracture of the acetabulum must be treated by 
means of a long splint, or hip splint of gutta-percha, 
molded to the side of the pelvis and thigh so as to 
fix the joint. A catheter should be introduced to 
ascertain the state of the bladder If bloody 
urine or other symptom of injury to this organ or 
to the urethra is present, the catheter must be 
kept in the bladder to prevent extravasation. See 
Bladder (Injuries). 
PEMPHIGUS.-Pemphigus is an acute or 
chronic inflammatory disease of the skin, char- 
acterized by the formation of successive crops of 
variously sized, rounded or oval bullse, affecting 
seriously the general health and often terminating 
fatally. 
Symptoms.-There are two principal types- 
pemphigus vulgaris and pemphigus foliaceus. 
Pemphigus Vulgaris.-With or without febrile 
disturbance, there appear upon the limbs, face, 
or trunk, pea-sized to egg-sized, rounded or oval, 
tense blebs. These rise abruptly from the normal 
skin, and, while having at times a slightly reddened 
base, have no areola. The contained fluid is at 
first serous, later becoming turbid and purulent. 
The eruption occurs in crops, a half of a dozen or 
more blebs appearing at a time. These persist 
for a few days (the fluid disappearing by absorp- 
tion or rupture), and are then followed by another 
crop. The parts most frequently affected are, 
in their order of frequency, the limbs, the face, 
and the trunk. The mouth, vagina, conjunctiva, 
and other mucous membranes may become in- 
volved. The disease in some cases runs a more 
or less acute course, getting well in a few months. 
Far more frequently, however, it persists for years, 
greatly impairing the general health. 
Pemphigus Foliaceus.-In this form the blebs, 
which are flaccid and purulent, rupture before 
distention and dry to crusts, which are thrown off 
with the surrounding epidermis, exposing to view 
the reddened corium. A new crop of blebs suc- 
ceeds the old, often developing upon the same 
site, and giving to the skin the appearance of a 
severe scald. The entire cutaneous surface may 
thus become involved, and the general health 
seriously compromised. The process lasts for 
months or years, and almost always leads to a 
fatal termination. 
Neumann has described a rare form of pem- 
phigus, characterized by the development of wart- 
like or papillary vegetations upon the sites of rup- 
tured bullse. This form he has called Pemphigus 
Vegetans. The mouth, vagina, or other mucous 
membranes are often first affected. The favorite 
situations upon the skin are the genital and anal 
regions, the neck, axillae, and flexures of the ex- 
tremities. The affection lasts months or years, 
and tends to a fatal termination. The subjective 
phenomena in pemphigus are itching and burning 
(usually moderate in degree), and often tenderness, 
pain, and a feeling of tension. The disease is 
distinctly rare, particularly in this country. 
Etiology is obscure. The disease has been ob- 
served in many cases in which marked changes in 
the central and peripheral nervous systems were 
noted. In addition, mental strain, nervous ex- PENIS, DISEASES 
PENIS, DISEASES 
haustion, and a lowered or vitiated state of the 
general health are considered to be causative. 
Pathology.-The blebs are usually situated 
between the horny layer and the rete mucosum, 
but may occur at any depth in the epidermis. 
The contents of the bullae consist of a slightly 
alkaline serum containing a few leukocytes. 
There is dilatation of the papillary vessels, and a 
leukocytic infiltration of the papillae, corium, 
and subcutaneous tissue. The affection is looked 
upon as a trophoneurosis. 
Diagnosis.-It should be remembered that all 
bullous eruptions are not pemphigus. Care should 
be exercised to differentiate the bullous forms of 
erythema multiforme, dermatitis herpetiformis, 
impetigo contagiosa, and syphilis (pemphigus 
syphiliticus of the older writers). The blebs of 
pemphigus are large, tense, abruptly elevated, 
noninflammatory, and come out in crops. These 
characteristics, with the history and course of the 
disease, should enable one to make the diagnosis. 
Prognosis.-The course of the disease is uncer- 
tain. Mild cases may recover after a duration of 
months. Severe cases (particularly pemphigus 
foliaceus) are likely to end fatally. The occur- 
rence of flaccid or hemorrhagic blebs, extensive 
cutaneous involvement, frequent outbreaks, or 
constitutional depression are all unfavorable signs. 
Treatment.-Both internal and local treatment 
are to be employed, the former alone, however, be- 
ing curative. Arsenic is by far the most valuable 
remedy. It is to be perseveringly tried, beginning 
with small doses and increasing until the physio- 
logic limit is reached. Quinin in full doses is also 
of value, as are, at times, iron, strychnin, and cod- 
liver oil. Nutritious food, good hygiene, and bodily 
and mental rest are important therapeutic factors. 
Local treatment is designed to heal the abraded 
surfaces and relieve the subjective symptoms. 
The blebs should be evacuated, and simple dusting- 
powders, ointments, or lotions applied. The cal- 
amin lotion is a most grateful application. Bran 
and starch baths are useful in extensive cases. In 
pemphigus foliaceus the continuous bath is per- 
haps the best treatment, the patient living day 
and night, for weeks and months, immersed in 
water. 
PENIS, DISEASES.-Inflammation is usually the 
result of injury or associated with venereal disease. 
Cuts, twists, "breaking" a chordee, ligation of the 
penis, or forcing rings over it, passage of instru- 
ments, and impactions from calculi are the ordi- 
nary injuries. Injuries to the perineum may 
result in inflammation of the penis from extension. 
Excessive sexual intercourse or persistent mastur- 
bation are causative agents in inflammation. It 
may be a sequel to the exanthems and diphtheria. 
It is also found in gouty and diabetic subjects. 
The treatment follows the general treatment of 
inflammation, with especial regard to the cause or 
condition in connection with which the inflamma- 
tion has arisen. 
Herpes of the penis is a vesicular eruption, 
occurring on the cutaneous or mucous surface of 
the prepuce, and running its course in about a 
week, but being liable to recur at stated intervals. 
Its recognition is important, because its appear- 
ance after doubtful intercourse may lead to im- 
proper treatment. A sedative lotion and the 
avoidance or prevention of all irritation are all 
that are needed in treatment. See Chancroid. 
Priapism.-The condition of temporary and 
functional fulness and firmness of the penis, 
clitoris, etc., due to sexual excitement, friction, 
spinal irritation, etc. The mechanism consists 
in an overfilling of the blood-vessels with an 
inhibition of the return circulation. 
Treatment.-Hyoscin hydrobromid, 1/120 to 
1/60 grain at bedtime, will prevent erections and 
check emissions. Belladonna in gradually in- 
creasing doses brings good results. Camphor 
often succeeds, while potassium and sodium bro- 
mids are especially sedative in irritable states of 
the genitourinary organs in which erections 
occur. Chloral, given at bedtime, may be repeated 
every night. A few drops of a 4 percent solution 
of cocain upon the glans penis often promptly 
controls an erection. Cold applications are of 
value. The anaphrodisiacs lower the sexual 
appetite and depress the genital centers in the 
brain and cord. See Anaphrodisiacs, Chordee, 
Gonorrhea. 
Deformities.-The roof may be defective (epis- 
padias) ; or the floor (hypospadias); or the invag- 
ination that forms the fossa navicularis may fail 
to meet the part behind. If the urethra is imper- 
forate, the kidneys become cystic, and the child 
dies at or before birth. Usually, however, there 
is hypospadias, and occasionally the two channels 
run one above the other for a considerable distance. 
Hypospadias.-The orifice is usually at the 
base of the glans, or a little further back; the 
frenum is absent; the prepuce forms a great 
fold on the dorsum like a caul, and the corpus 
spongiosum possesses scarcely any erectile tissue. 
In other cases it lies at the end of the membranous 
urethra, the bulb and the scrotum failing to unite 
in the middle line, and forming labia, as in the 
female. When the defect is slight, the fossa 
navicularis may run back and end blindly; in other 
cases the penis is small, and the corpus spongiosum, 
if it is developed, incapable of erection. 
Epispadias.-The complete form is always asso- 
ciated with ectopia vesicse; occasionally the ure- 
thra opens behind the corona, the rest of the 
penis being well developed. 
The treatment is not very promising. If the 
defect is slight, and micturition not impeded, it is 
better not to interfere. The orifice should be 
dilated to prevent any strain upon the structures 
behind; and if the urethra fails in front, so that 
it is impossible to direct the stream, an attempt 
should be made to carry it forward by means of a 
plastic operation. The flap must be double, so 
that a cutaneous surface may face the new channel; 
the deeper layer is taken from the side of the penis 
near, and twisted round upon itself; the super- 
ficial one borrowed from the redundant prepuce, 
the center of the caul being dissected up, and the 
glans thrust through the opening, so that the 
dorsal surface becomes inferior, or vice versa, as 
the case may be. PENIS, DISEASES 
PEPSIN 
Phimosis may be congenital or acquired, follow- 
ing balanitis, soft sores, chancre, or injury. In 
the former case the glans is often adherent, and 
the orifice may be reduced to the size of a pinhole, 
so that the prepuce swells out with each act of 
micturition. Circumcision should always be per- 
formed, unless the corona can be thoroughly and 
easily exposed; the secretion collects inside; 
there is a constant risk of balanitis and para- 
phimosis; preputial calculi may form; and the 
liability to syphilis and phagedena is much greater. 
If gonorrhea occurs, it is more severe, and the 
constant irritation undoubtedly favors carcinoma. 
Circumcision.-In the operation of circumcision 
the prepuce is drawn well forward, and clipped 
with a pair of polypus forceps in front of the glans; 
the projecting end cut off; the cutaneous sheath 
allowed to retract, and the mucous membrane slit 
up along the dorsum as far as its attachment. 
Each half is then cut away, following the line of the 
corona, and leaving the frenum and just enough to 
hold a few sutures. If catgut is used, and the 
wound dried and covered with iodoform, the 
dressing may remain on until the skin has united. 
Paraphimosis is the condition produced by forc- 
ing the glans through the orifice of the prepuce 
when it is too narrow to admit it. The imme- 
diate result is congestion and inflammation, end- 
ing, if left, in ulceration and sloughing. The 
glans becomes swollen; the prepuce overhangs it 
like an edematous collar, and concealed behind 
this is a tight, unyielding ring formed by the 
orifice. In early cases reduction can usually be 
effected by oiling the parts well, and drawing the 
foreskin forward with the index- and middle 
fingers of the two hands, while the thumbs com- 
press the glans; or the penis may be wrapped round 
with lint soaked in equal parts of adrenalin solution 
1 : 1000 and cocain solution 1 : 100; this is left on 
for 15 minutes, when the edema disappears, and 
reduction is often easy. In cases that have 
already lasted some days, it is often necessary to 
slip the end of a director under the constricting 
band on the dorsum, and divide it with a bistoury. 
Epithelioma.-Squamous epithelioma is not un- 
common after middle life, commencing on the 
glans or the inner surface of the prepuce, especially 
in cases of phimosis. It usually begins as a warty 
nodule, which soon breaks down into an ulcer, 
with intensely hard base and edges. If allowed 
to remain, the growth spreads rapidly, owing to 
the constant irritation of the urine; the corpora 
cavernosa and the glans are quickly infiltrated; 
the lymphatics in the groin become involved, and 
secondary deposits follow. The diagnosis from 
syphilis rests chiefly on the character of the base, 
which is covered with decaying epithelium, and 
the intense induration beneath and around. 
Treatment.-Amputation is the only treatment. 
Until recently this was accomplished either with 
a single sweep of the knife, or more deliberately, 
forming a flap of skin to cover the surface of the 
wound, leaving the corpus spongiosum and the 
urethra longer than the rest, and stitching the 
edge of the mucous membrane to that of the skin. 
Recurrence, however, is exceedingly common 
after this operation; cicatricial stricture at the 
orifice invariable; and all power of directing the 
stream of urine lost. To avoid this, Thiersch 
recommends an oval incision round the root of 
the penis, prolonged a little backward in the 
median raphe of the scrotum, and then dissect- 
ing off the whole of the corpora cavernosa 
from the rami of the pubes and the triangular 
ligament. The corpus spongiosum and the ure- 
thra are dealt with separately, through an incision 
in the median line of the perineum behind, as 
much being removed as appears desirable, and the 
rest sutured to the skin in front of the anus. 
Micturition must, of course, be effected in the 
sitting posture, but there is not the same tendency 
to the formation of stricture, and there is much 
further freedom from return of the growth. 
Benign Tumors.-Of these there are cystic, 
vascular, fibrous, horny, fatty, sebaceous, and 
other new growths. The most common are the 
papillomata or warty growths, which are associated 
chiefly with venereal disease. They may arise 
from uncleanliness, especially if the prepuce is 
long. They constitute a "cauliflower" mass, 
and sometimes completely cover the mucous 
surface of the glans and prepuce. Removal by 
scissors, or by torsion with forceps, is a most 
speedily effectual treatment. Repeated applica- 
tions of zinc, calomel, tannic acid, burnt alum, 
or the pressure of dry lint between the foreskin 
and glans may suffice. Cleanliness is essential. 
PENNYROYAL.-See Hedeoma. 
PEPO.-Pumpkin seed. The ripe seed of 
Cucurbita pepo, with properties due to a resin 
contained in the inner covering of the embryo. 
Dose of the resin, 15 grains; of the seeds 1/2 to 
11/2 ounces, made into a suitable emulsion. 
It is efficient and harmless used as a vermifuge 
against the tape-worm. The husks should be 
removed and the remainder rubbed into an emul- 
sion with water, or into an electuary with sugar, 
should be taken on an empty stomach, and 
followed in 1 or 2 hours by an active purge. See 
Anthelmintics, Worms (Tape-). 
PEPPER.-See Piper. 
PEPPERMINT.-See Mentha Piperita. 
PEPSIN.-A name for the hypothetic digestive 
principle in the gastric juice, unknown as a definite 
body. All preparations vary much. Pepsin 
forms either a fine, white or yellowish-white, 
amorphous powder, or thin, translucent scales or 
grains, free from any offensive odor, soluble in 
about 100 parts of water, more soluble in water 
acidulated with hydrochloric acid, but insoluble 
in alcohol, ether, or chloroform. It should never 
be alkaline. Commercial pepsin is obtained from 
the rennet bags of sheep or the stomachs of pigs. 
It is precipitated by sodium chlorid, lead acetate, 
or by drying the peptones on glass plates. Alco- 
hol also precipitates it. Saccharated pepsin con- 
sists of 1 part pepsin, triturated with 9 parts of 
sugar of milk. One part should digest at least 
300 parts of egg-albumen. The dose is 5 grains 
to 1 dram, given shortly after meals. Liquid 
pepsin contains 40 parts of saccharated pepsin, 
12 of hydrochloric acid, 400 of glycerin, and PEPTONIZED FOOD 
PEPTONURIA 
enough water to make 1000 parts. The dose is 
2 to 4 drams, after meals. 
Every manufacturer of pepsin has his own 
preparation, with his peculiar name, but all prep- 
arations have in some degree the power of digest- 
ing albumin or fibrin. 
Pepsin is a ferment, not a solvent; it converts 
casein, albumin, fibrin, and other albuminoids 
into peptones for assimilation, being aided by 
lactic and hydrochloric acids. It should be given 
within 2 or 3 hours after taking food. Its activity 
is destroyed by alcohol, and .alkalies and many 
mineral acids precipitate it. It is chiefly em- 
ployed in dyspepsia, and in apepsia of infants, 
gastralgia, anemia, chlorosis, gastric ulcer and 
cancer, infantile diarrhea, and in the vomiting of 
pregnancy. 
It is added to rectal enemata of nutritive char- 
acter, and when injected into fatty tumors or 
morbid growths homologous to the tissues, may 
arrest their growth and promote absorption. 
Among the laity it is a much overrated remedy for 
indigestion. Pancreatin is usually of more service. 
In indigestion with atony: 
1$. Strychnin, gr. 1/24 
Powdered pepsin, gr. x 
Powdered starch, gr. vij. 
Give at 1 dose. 
PEPTONIZED FOOD.-This is indicated when 
the natural digestive powers are enfeebled or sus- 
pended. In gastric catarrh, with pain and in- 
tolerance of food, in gastric ulcer, in anorexia and 
dyspepsia associated with valvular heart-disease, 
and in pyloric and intestinal obstruction, in defec- 
tive nutrition and intestinal irritation, it is service- 
able. Peptonized food does not keep well, espe- 
cially in warm weather. It should be prepared 
twice daily, and never be given when more than 
12 hours old, or after having been reboiled. Pep- 
tonized food may be prepared by the gastric 
method, using pepsin and hydrochloric acid, or by 
the intestinal method, making use of the extract 
of pancreas. The latter is the preferable method. 
Probably the best solvent for an extract of pan- 
creas is dilute spirit. The pancreas of the pig 
yields the best or most active preparation, but 
that of the ox or sheep may be employed. Calf 
pancreas yields an active extract, not, however, 
affecting starchy materials. 
To make an extract of pancreas, first free the 
pancreas from fat, and cut into small pieces. 
Mix with 4 times its weight of dilute spirit, cork 
in a wide-mouthed bottle, and set aside for a week, 
agitating once daily, at the end of which time it is 
strained through muslin and then filtered through 
paper until clear. 
Peptonized Milk.-Heat a pint of milk mixed 
with half a pint of water to about 140° F., or heat 
one-half of the milk and water to the boiling- 
point, and add to the other (cold) half 2 teaspoon- 
fuls of the extract of pancreas and 10 grains of 
sodium bicarbonate. Pour into a covered jug and 
place in a warm situation. In an hour or hour and 
a half it is to be boiled for 2 or 3 minutes and 
may then be used like ordinary milk. 
Peptonized Gruel.-It may be prepared from 
wheaten flour, oatmeal, arrow-root, sago, pearl- 
barley, pea or lentil flour. The gruel should be 
well boiled, thick, and strong, and poured into a 
jug and allowed to become lukewarm. Pancre- 
atic extract, a dessertspoonful to a pint of gruel, 
may then be added, and the jug kept warm for 2 
hours or so, and then the gruel brought to a boil 
and strained. This gruel is not generally an ac- 
ceptable food for invalids, but it serves as a basis 
for peptonized soups, jellies, and blanc-manges. 
Peptonized Milk-gruel.-This may be regarded 
as a predigested bread and milk, and is especially 
useful for weak digestions. Thick gruel from fari- 
naceous articles, while boiling hot is added to an 
equal quantity of cold milk. To each pint of 
this mixture 2 or 3 teaspoonfuls of extract of 
pancreas and 10 grains of sodium bicarbonate are 
added. It is then treated as peptonized milk or 
gruel. If too bitter, less pancreatic extract may 
be used. 
Peptonized Soups, Jellies, and Blanc-manges.- 
One way of making soups is to add to peptonized 
milk or gruel what is known as " stock." A better 
way is to use thin and watery peptonized gruel 
instead of simple water for extracting the soluble 
matters of shins of beef and other materials used in 
preparing soups. Jellies may be made by simply 
adding the due quantity of gelatin or isinglass to 
hot peptonized gruel and flavoring to suit. Blanc- 
manges are made in the same way, using pepton- 
ized milk instead of gruel, and adding cream. If 
the final boiling in the preparation of the pepto- 
nized gruel or milk is not complete, the extract 
will act on the gelatin, and the power of setting on 
cooling will be lost. 
Peptonized Beef-tea.-To a pint of water are 
added a pound of finely minced lean beef and 10 
grains of sodium bicarbonate. Allow this com- 
bination to simmer for an hour and a half in a 
covered sauce-pan. Decant the ensuing beef-tea 
into a covered jug. Beat up with a spoon the 
undissolved beef residue into a paste, and add to 
the tea in the jug. When it is cool enough to be 
tolerated in the mouth, a tablespoonful of the 
extract of pancreas is to be added, and the whole 
stirred together and kept warm for 2 hours, being 
occasionally agitated, at the end of which time the 
contents of the jug are boiled for 2 or 3 minutes, 
and finally strained. Beef-tea prepared in this 
way contains about 4 percent organic residue, of 
which more than three-fourths consists of pep- 
tone. When seasoned with salt, its taste resem- 
bles ordinary beef-tea. 
Peptonized Enema.-To the enema prepared in 
the usual way-with a mixture of milk and gruel, 
or of milk alone, or of gruel and beef-tea-is added, 
just before administration, a dessertspoonful of 
liquor pancreaticus, or extract of pancreas. The 
ferment, in the warm temperature of the bowel, 
acts favorably, and no acid secretion interferes 
with the completion of the digestive process. It 
is a valuable resource when the stomach is intol- 
erant of food, or obstruction exists in higher por- 
tions of the digestive tract. 
PEPTONURIA.-The presence of peptone in PERCENTAGE SOLUTIONS 
the urine. The proteid body found in the urine 
in peptonuria is really not a peptone but an albu- 
mose, and a better term would be albumosuria. 
Albumose is characterized by yielding the biuret 
reaction; it is not precipitated by heat, but is 
precipitated by ammonium sulphate. Pepton- 
uria-i. e., albumosuria-occurs in all conditions 
attended by the destruction of tissue, especially in 
suppurative processes, purulent pleurisy, purulent 
peritonitis, abscesses, cerebrospinal meningitis, 
pyelonephritis, bronchoblennorrhea, in some cases 
of pulmonary tuberculosis with cavity formation, 
and during the puerperal state. The blood in 
leukemia may also contain albumose. Propepto- 
nuria is probably only an albumosuria of high 
degree. See Urine. 
PERINEUM, INJURIES 
scope at a fixed point and percussing gently all 
around. The stethoscope may be held with one 
hand, while with a finger of the other immediate 
percussion is made; or an assistant may percuss. 
See Chest (Examination). 
PERICARDITIS.-See Heart-disease (Organic.) 
PERICARDIUM, INJURIES.-See Heart (In- 
juries). 
PERIHEPATITIS.-See Liver. 
PERIMETER.-See Field of Vision. 
PERINEUM, INJURIES.-Injuries to the peri- 
neum are almost invariably the result of childbirth. 
They are classified, according to the extent and posi- 
tion of the injury, into: (1) Slight median tear not 
involving the anal sphincter; (2) median tear in 
which the sphincter is divided; (3) laceration in 
one or both vaginal sulci; and (4) subcutaneous 
laceration of the muscles and fascia. 
These injuries should be repaired by perineor- 
rhaphy. Primary perineorrhaphy, or repair of the 
injury within the first few hours after labor, is 
preferable. When this cannot be done, or when 
it has been neglected, secondary perineorrhaphy 
should be performed. This may be done any 
time after cicatrization has occurred. 
Slight Median Tear not Involving the Sphincter.- 
This tear passes through the fourchet, and may 
extend down the median line of the perineum as 
far as the sphincter. It usually extends for 1/2 
of an inch or more up the posterior vaginal wall. 
In this injury there is no involvement of the sup- 
porting structures of the pelvic floor, and, there- 
fore, there is no tendency toward prolapse of the 
vaginal walls and pelvic organs. This tear should 
be closed immediately after labor by the intro- 
duction of sutures, as shown in the accompanying 
illustration. The first stitch should be introduced 
at the apex of the tear in the posterior vaginal 
wall. It should be carried well out, so as to in- 
clude sufficient tissue, and should emerge at the 
bottom of the tear; it should be reintroduced here, 
to be brought out on the opposite side of the tear 
at a point corresponding with its first point of 
introduction. Sufficient stitches should be intro- 
duced, about 1/4 inch apart, to completely close 
the wound. The external tear should be closed 
in a similar manner. The sutures may be tied or 
shotted. If this tear is neglected at the time of its 
occurrence, the secondary operation of perine- 
orrhaphy is not indicated. 
Median Tear in Which the Anal Sphincter is 
Divided.-This tear, although an extensive one, 
does not injure the supporting structures of the 
pelvic floor. There is, therefore, no tendency 
toward prolapse of the pelvic organs or the vaginal 
walls. The laceration takes place in the median 
line of the perineum, extends through the sphincter 
muscle, and may involve the rectovaginal septum 
to a greater or less extent. Permanent incon- 
tinence of feces is the result of this injury. 
It is of the utmost importance that an injury of 
this character be repaired immediately after labor 
The stitches are introduced as follows: The tear 
in the rectovaginal septum should first be closed 
by interrupted sutures, placed about 1/4 inch 
apart. They should be introduced from the 
Based on 456 Grains as the Weight of One Fluid 
Ounce of Water. 
PERCENTAGE SOLUTIONS, TABLE OF. 
Dissolve the quantity of ingredient (in grains) in less water 
than the required volume of solution, and then add sufficient 
water to bring the solution up to the required volume. 
- 
- 
- 
- 
- 
Solution 
3j. 
3ij. 
5iv. 
3vj. 
Pint 
Qt. 
Gal- 
lon. 
iAo p.c., 1:10,000 
ft 
ft 
3 
ft 
3 
13 
6 
so p.c., 1:5,000 
i1® 
3 
A 
3 
13 
3 
12 
ft P-c., 1:3,000 
1 
A 
ft 
ft 
2 
5 
193 
A p.c., 1:2,000 
3 
3 
9 
10 
13 
33 
7i 
29 
ft p.c., 1:1,000 
3 
ft 
2 
3 
7i 
143 
58 
i p.c., 1:800 
ft 
1 
2i 
33 
9 
18 
73 
£ p.c., 1:500 
A 
2 
33 
53 
143 
29 
117 
i p.c., 1:400 
1 
2i 
43 
7i 
18 
36 
146 
3 p.c., 1:300 
13 
3 
6 
9 
24 
49 
195 
3 p.c., 1:200 
2i 
43 
9 
14 
36 
73 
292 
3 p.c., 1:150 
3 
6 
12 
18 
47 
95 
379 
ft P-c., 1:111 
4 
8 
16 
25 
65 
131 
525 
1 p.c., 1:100 
43 
9 
18 
27 
73 
146 
584 
2 p.c., 1:50 
9 
18 
36 
55 
146 
292 
1167 
3 p.c., 1:333 
14 
27 
55 
82 
219 
438 
1751 
4 p.c., 1:25 
18 
36 
73 
110 
292 
584 
2335 
5 p.c., 1:20 
23 
46 
91 
137 
365 
730 
2918 
7 p.c., 1:14.28 
32 
64 
128 
192 
511 
1021 
4086 
10 p.c., 1:10 
46 
91 
182 
274 
730 
1459 
5837 
12 p.c., 1:83 
55 
109 
219 
328 
876 
1751 
7004 
15 p.c., 1:6$ 
68 
137 
274 
410 
1094 
2189 
8755 
20 p.c., 1:5 
91 
182 
365 
547 
1459 
2918 
11673 
30 p.c , 1:33 
137 
274 
547 
821 
2189 
4378 
17510 
40 p.c., 1:23 
182 
365 
730 
1094 
2918 
5837 
23345 
50 p.c., 1:2 
228 
456 
912 
1368 
3648 
7296 
29184 
(Potter.) 
PERCUSSION.-A method of physical exami- 
nation applied by striking upon any part of the 
body, with a view of ascertaining the conditions 
of the underlying organs by the character of the 
sounds elicited. In percussing attention is paid 
to the resonance, the pitch, and the duration of the 
sound, and to the resistance of the parts. Per- 
cussion is sometimes performed by striking with 
the entire hand. The method, in the case of the 
chest, serves to distinguish marked degrees of 
dulness from resonance. 
Auscultatory percussion is percussion combined 
with auscultation. The method by which fine 
shades of difference in the quality of sounds may 
be detected. It is employed for outlining organs, 
both those containing and those not containing 
air. It is best applied by placing a double stetho- PERINEUM, INJURIES 
PERITONITIS 
vaginal aspect, beginning at the apex of the tear, 
and should extend to, but not through, the rectal 
mucous membrane. These sutures should now be 
shotted. The sutures which bring together the 
divided ends of the sphincter ani muscle are next 
introduced. This is obviously the most important 
step of the operation, since failure to bring to- 
gether the ends of this muscle will result in con- 
tinued incontinence of feces. The ends of the 
divided muscle are usually clearly marked by a dim- 
ple well back of and to each side of the anal opening. 
The first suture is introduced from the skin surface, 
back of and to the inner side of this dimple, close 
to the rectal mucous membrane. It is passed up- 
ward and outward through the dimple, and finally 
inward, to emerge at the apex of the tear in the 
rectovaginal septum, or if the septum has been 
extensively torn and repaired, just below the last 
stitch in the septum. It is reintroduced here, 
and is passed outward, downward, and inward 
through the septum, to emerge on the skin of the 
perineum just below the dimple of the opposite 
side. For greater security, a second similar stitch 
is introduced a little to the outer side of the first 
one. The subsequent steps of the operation con- 
sist in closure of the external perineal tear by a row 
of interrupted stitches. These stitches are now 
shotted, the two sutures holding the sphincter ani 
being secured first. If this injury is neglected at 
the time of its occurrence secondary perineor- 
rhaphy must be performed. The technic of this 
operation is similar to that just described, except 
that the torn surface will have to be denuded. 
This is done with sharp scissors, particular care 
being taken to expose the ends of the divided 
sphincter muscle. 
Laceration in One or Both Vaginal Sulci.-This 
tear extends in the direction of the ischiorectal 
fossa, and divides the vaginal sphincter, the trans- 
verse perineal muscle, and the inner fibers of the 
levator ani. The anal sphincter usually escapes, 
since it is out of the line of injury, which is usually 
bilateral, the left sulcus being, as a rule, the more 
extensively torn. 
The result of this injury is prolapse of the vaginal 
walls and pelvic organs, since the supporting 
structures of the pelvic floor are lacerated. Re- 
pair should be immediately undertaken by first 
closing the torn sulci, and finally the tear of the 
external perineum in the manner that is described 
under the secondary operation. 
The best secondary operation for the repair of a 
tear involving the sulci is Emmet's, which is per- 
formed as follows: The crest of the rectocele is 
seized with a tenaculum; the labia majora are 
seized with tenacula at about the height of the 
orifice of the ducts of the vulvovaginal glands. If 
the rectocele is drawn to one side, a triangular area 
is exposed which represents the site of the old 
laceration. This area is next denuded. The rec- 
tocele is now drawn to the opposite side, when a 
similar area is exposed and denuded. The base of 
the rectocele and a small portion of the skin of the 
perineum are next denuded. In denuding these 
areas care should be taken to remove every particle 
of scar tissue and mucous membrane. 
The stitches are next introduced, the sulci being 
closed first. The first stitch passes directly across 
the apex of the tear in the left sulcus. The second 
stitch is introduced about 1/4 inch lower down, 
and about 1/8 inch from the edge of the mucous 
membrane on the left vaginal wall; it passes out- 
ward, downward, and inward, emerging at the 
bottom of the sulcus. It is reintroduced here, and 
emerges on the edge of the mucous membrane of 
the rectocele at a point corresponding to its point 
of insertion. A third, and sometimes a fourth, 
suture is introduced in a like manner. Similar 
stitches are introduced in the right sulcus. 
The skin of the perineum is now closed by a 
suture which is known as the crown stitch. It is 
introduced on the skin, passes outside of the de- 
nuded area, and emerges at the edge of the mucous 
membrane of the left lateral vaginal wall just 
below the last suture in the sulcus. It is then 
passed through the rectocele below the mucous 
membrane, and finally through the lateral de- 
nudation of the opposite side. A second suture, 
somewhat like the crown stitch, is usually necessary. 
The sutures in the sulci are first shotted, and 
finally those which close the skin of the perineum. 
Subcutaneous Laceration of the Muscles and 
Fascia.-In this tear the muscles and fascia are 
injured, while the mucous membrane and skin 
remain intact. This is due to the great elasticity 
of the latter, which enables them to stretch, while 
the deeper structures, which are less elastic, tear. 
This injury invariably occurs in the sulci, and its 
results and treatment are the same as the pre- 
ceding tear. It is sometimes called relaxation of 
the perineum. The best suture material for the 
foregoing operation is silkworm-gut. After the 
operation is completed, a douche of sterile water 
is given and a light vaginal tampon of iodoform 
gauze is introduced. This tampon is removed at 
the end of 24 hours. The bowels are moved on 
the third day. The stitches are removed at the 
end of 2 weeks, after which the patient may get 
out of bed. She should avoid heavy lifting, long 
standing, or any other form of active or tiresome 
exercise for at least 2 months after the operation. 
PERIOSTITIS.-See Bone (Diseases). 
PERISPLENITIS.-See Spleen (Diseases). 
PERITOMY.-See Pannus, Trachoma. 
PERITONITIS.-Inflammation of the peri- 
toneum. According to cause it may be primary 
or secondary; according to extent, local or general; 
according to time, acute or chronic; and accord- 
ing to the exudate, serofibrinous, fibrinous, or 
purulent. 
Etiology.-(1) Traumatic; (2) secondary to a 
suppurative process elsewhere, as abscess, pyo- 
salpinx, endometritis, appendicitis; (3) secondary 
to obstruction of the bowels with infection; (4) 
secondary to certain diseases, as typhoid fever, 
hepatic abscess, empyema of the gall-bladder, 
tuberculosis, nephritis, or rheumatism. (See 
Colon Bacillus Infection.) Idiopathic peri- 
tonitis is no longer recognized. Traumatic peri- 
tonitis, following chemical irritation as well as 
injury, gives rise to distinctly localized trouble 
and is very different from true acute peritonitis, PERITONITIS 
PERITONITIS 
which is always caused by bacterial infection. 
In the former condition the elevation of temper- 
ature is probably caused by the absorption of 
fibrin ferment or other chemical substance gene- 
rated in the injured tissues. 
the early stage of the disease, are not only devoid 
of curative effect but undoubtedly are harmful 
in that they may cause dissemination of an infec- 
tion which nature is endeavoring to localize. 
A movement of the bowels may be obtained by a 
simple or medicated enema. Neither food nor 
drink should be given by the mouth, but enough 
fluid given by rectum to relieve thirst. As diag- 
nosis is usually not difficult in the early cases an 
exploration can be made with no little degree of 
assurance that the causative lesion will be found 
and removed. The later cases constitute one of 
the most difficult problems of surgery. As a 
general rule it may be stated that the decision to 
operate or not to operate will depend upon the 
degree of collapse from which the patient is suffer- 
ing. Each case of this kind must be decided upon 
its own merits as there is no invariable rule which 
will apply to all. In operations in these cases all 
delaying minutiae of technic should be disregarded. 
The abdomen is opened, the cause of the perito- 
nitis removed, if possible, and drainage made 
through the original wound and also through a 
suprapubic incision. The postoperative treat- 
ment is very important. John B. Murphy has 
taught the profession the value of introducing 
large quantities of water or salt solution into the 
rectum by means of a constant though gentle flow. 
The patient is placed in the high-head (Fowler's) 
position and a nozzle, perforated in three or four 
places and attached to a container by a rubber 
tubing, is inserted into the anus. The container 
is placed but a few inches above the level of the 
rectum, so that the fluid shall flow in very slowly, 
no faster than it is absorbed. The flow may be 
regulated by compressing the tube, so that no 
fluid shall accumulate in the bowel. From a pint 
to a quart will ordinarily be absorbed in an hour. 
(See Proctoclysis.) In addition to the institu- 
tion of this measure, food by the mouth is with- 
held, in order to prevent peristalsis. Concentrated 
liquids may be given by rectum either separately 
or mixed with the fluid used for proctoclysis. 
Strychnin and morphin given hypodermatically 
may be used according to the indications of the 
individual case. 
Acute Peritonitis. 
Pathology.-The membrane is red, swollen, and 
covered with an exudate-serofibrinous, fibrinous, 
or purulent. Frequently the coils of intestines are 
glued together through the medium of the inflam- 
matory creamy exudation, which in many cases 
undergoes organization with the formation of 
fibrous bands. The endothelium undergoes des- 
quamation or is infiltrated with liquid, and if 
infection takes place, fatty degeneration ensues, 
with the formation of pus. The usual infective 
microorganisms are the bacillus coli communis and 
the streptococcus. 
Symptoms and Clinical Course.-Diffuse pain 
over the entire abdominal region and abdominal 
distention are the two most characteristic symp- 
toms. On pressure over this area the patient 
complains of excessive tenderness, and, as in 
appendicitis, the dorsal decubitus is assumed to 
relieve as much as possible the tension of the 
abdominal muscles. Vomiting is an early symp- 
tom: first the contents of the stomach are ejected, 
and later the vomitus has a greenish tint, showing 
the presence of bile. The bowels are obstinately 
constipated; the temperature is considerably 
elevated (103° to 104° F); the pulse is rapid (120 to 
140), small, hard, and of a wary character; the 
respirations are increased in number (30 to 40), and 
deep breathing is painful on account of distention 
of abdomen; the skin is moist and cold, devoid of 
color; the eyes are sunken; the cheek bones are 
prominent; the nose is pinched, giving rise to the 
Hippocratic facies. When the case terminates 
favorably, the fluid may be collected in sacs formed 
by the adhesion of the peritoneum to that of the 
intestine, and small areas of dulness may be found. 
The duration of an acute attack of peritonitis is 
from 6 to 9 days. 
Diagnosis.-See table under Intestinal Ob- 
struction. 
Prognosis is always grave, but modern methods 
of treatment have lowered the mortality rate. 
The pulse is the best index of the gravity of the 
infection. 
Treatment.-Medical treatment offers little 
hope in this affection. The cases which terminate 
favorably under its employment would probably 
do equally as well if no drugs were used. The 
key-note of success is early determination and 
removal by surgical means of the causative lesion. 
Opium should never be given until a diagnosis has 
been made, as it obscures the symptoms and also 
confers a false sense of security upon the patient, 
who naturally thinks that the relief of pain which 
follows its administration is a sign that his con- 
dition is improving. In cases in which operation 
is refused and in those in which the surgeon is 
called when it is too late to operate, then of course 
its use is permissible. Saline cathartics, at one 
time highly esteemed by some practitioners in 
Chronic Peritonitis. 
A form of peritonitis of slow development, and 
generally secondary to some constitutional disease. 
It occurs in two forms, circumscribed adhesive or 
diffuse proliferative. 
Etiology.-(1) Most frequently tuberculosis; 
(2) cancer; (3) nephritis; (4) chronic alcoholism, 
are the most common etiologic factors. 
Pathology.-The coils of intestines are often 
firmly matted together, and bands of adhesions 
connect the intestine to the peritoneum, often 
forming pouches in which fluid may be present. 
Its color in tuberculosis and in malignant diseases 
is usually reddened from the presence of blood. 
Symptoms and Clinical Course.-The symptoms 
at first are very indefinite, though a sense of 
tenderness may be complained of on pressure over 
the affected area. The abdomen becomes re- 
tracted and hardened, a stiff, rigid abdomen being PERITYPHLITIS 
PHARYNGITIS 
quite characteristic of tubercular peritonitis. 
Later tympany is present especially in the upper 
part of the abdomen. Ascites may be present. 
Localized swellings may occur, giving rise to pain 
and edema on pressure. The temperature is 
usually normal, or only slightly elevated. Con- 
stipation and albuminuria are common. 
Prognosis is unfavorable. 
Treatment is palliative by opium and other 
appropriate remedies. Treatment for tubercu- 
losis (g. v.) should be instituted in the tubercular 
form. When ascites is present, or there is a 
purulent condition, the surgeon should perform 
a celiotomy. An incision is made in the median 
line evacuating the serum or pus, and, by a lifting 
motion of the abdominal wall, causes a free access 
of air within the peritoneal cavity. Abscesses 
found may be iodoformized after evacuation and 
drying. The abdomen should be closed without 
drainage. Secondary infection and fecal fistula 
are apt to result from the use of a drain. Results 
have been most encouraging, although surgeons 
do not agree as to the way in which the cure is 
produced. Dense adhesion of the intestines to the 
abdominal wall takes place in the course of a cure. 
PERITYPHLITIS.-Inflammation of the perito- 
neum surrounding the cecum. This is a disease 
most frequently encountered in the young and in 
males. It is usually due to some inflammatory 
disease of the vermiform appendix, and is marked 
by pain in the right iliac fossa, and a tumor- 
elongated, sausage-shaped, dull on percussion, and 
very tender-in the same region. The disease 
may give rise to general peritonitis from escape of 
pus into the general peritoneal cavity. The 
abscess may burst through the abdominal wall 
into the bowels, bladder, or pleural cavity. See 
Appendicitis. 
PERMANGANATE, POTASSIUM.-See Man- 
ganese. 
PERNICIOUS ANEMIA.-See Anemia (Per- 
nicious). 
PERNIO.-See Frost-bite. 
PERSPIRATION.-See Diaphoretics, Sweat- 
glands. 
PERTUSSIS.-See Whooping-cough. 
PESSARY.-See Uterus (Retrodisplacements). 
PETECHIA.-A small, round, oval, or irregular 
spot of ecchymosis beneath the epidermis, varying 
in size from a flea-bite to an area having a dia- 
meter of 1/2 inch or more. It is not raised above 
the level of the skin, but is of a reddish or purple 
shade, and does not alter by pressure of the finger. 
Flea-bites have in them a puncture which is 
always perceptible, and which contrasts strongly 
with the lighter color of the rest of the disc. The 
tint varies according to age and the amount of 
effused blood. They occur on mucous membranes 
as well as on the skin, in purpura, scorbutus, ma- 
lignant fevers, and in constitutional diseases. 
The term petechial is applied to certain varieties of 
diseases, such as typhus, when petechiae occur in 
their course, or the eruption becomes hemorrhagic. 
PETROLATUM.-A mixture of hydrocarbons, 
chiefly of the methane series, obtained from 
petroleum. It is colorless or yellowish, and in the 
latter case is more or less fluorescent; amorphous, 
odorless and tasteless, of neutral reaction, in- 
soluble in water, slightly soluble in absolute 
alcohol, readily soluble in ether, chloroform, 
petroleum benzin, benzene, carbon disulphid, oil 
of turpentine, and fixed or volatile oils. The soft 
variety is known commercially as terralin, cos- 
molin, vaselin, petroleum ointment, etc. Besides 
petrolatum itself it is official in the following- 
named forms-P. Album, a white, unctuous 
mass, without odor or taste, of about the con- 
sistence of an ointment. P. Liquidum, a color- 
less, oily, transparent liquid, without odor or taste, 
but giving off, when heated, a faint odor of pe- 
troleum. Paraffinum, a mixture of solid hydro- 
carbons, a colorless, translucent mass, odorless 
and tasteless, and slightly greasy to the touch. 
Petrolatum is a valuable protective dressing, 
and an excellent basis for ointments, having no 
acridity and no liability to become rancid. It is 
readily miscible with many active agents, as the 
alkaloids and phenol compounds, but it does not 
penetrate the skin so readily as animal fats and 
fixed oils. Uncombined, it forms an excellent 
bland application in all irritated conditions and 
injuries of the skin, and it has been used with 
benefit alone, or mixed with castor or olive oil, 
in chronic eczema accompanied by desquamation. 
Paraffin is employed by subcutaneous injection 
for cosmetic effects on saddle-shaped noses and 
other superficial -deformities. 
PHAGEDENA.-See Ulcer. 
PHARYNGITIS (Simple Angina).-An inflam- 
mation of the mucous membrane of the pharynx, 
and also very frequently involving the soft pal- 
ate, uvula, tonsils, and larynx. 
Varieties.-(1) Acute pharyngitis; (2) chronic 
pharyngitis. 
Acute Pharyngitis. 
Definition.-An acute catarrhal inflammation of 
the mucous membrane of the pharynx. 
Etiology.-(1) Exposure to the cold and wet; (2) 
overheated sitting or sleeping room, with a sudden 
chilling; (3) sedentary habit, with indigestion and 
constipation; (4) certain diseases, such as tuber- 
culosis, gout, rheumatism, and lithemia; (5) 
inhalation of steam, dust, or noxious vapors. 
Symptoms.-There is pain on swallowing, 
accompanied by a sensation of dryness or of a 
foreign body, and a desire to clear the throat. 
Tenderness may exist in muscles in region of 
neck and pain may arise from pressure over the 
region of the tonsils; for this reason in many cases 
the mouth cannot well be opened. Should the 
catarrhal process extend upward, the orifices of the 
eustachian tubes may become occluded, giving 
rise to temporary deafness or ringing in the ears; 
and if it extends downward into the larynx, 
hoarseness will be added to the other symptoms. 
Often the senses of taste and smell are temporarily 
impared. 
Physical Signs.-On inspecting the pharynx it 
will be seen to be greatly reddened in color and 
the blood-vessels in a condition of hyperemia, 
especially on the posterior wall, and the uvula PHARYNGITIS 
PHARYNGITIS 
and fauces may be edematous. See Pharynx 
(Examination). 
Prognosis is favorable. 
Treatment.-Rest in bed is essential; free purga- 
tion at the onset is desirable. Calomel (1/6 grain) 
should be given every hour until 6 or 8 doses have 
been taken, followed by a saline purge. A hot 
mustard foot-bath at bedtime is recommended. 
A commendable prescription is: 
1$. Tincture of aconite, rr[ xlv 
Solution of potassium citrate, 3 ij 
Aromatic elixir, 5 iv 
Camphor water, add enough 
to make, 3 iv. 
One tablespoonful every 3 hours. 
If there is much edema: 
I}. Tincture of opium, 5 j 
Tincture of belladonna, n| xv 
Camphor water, add enough 
to make 3 iv. 
One tablespoonful every 3 or 4 hours. 
Also apply locally boroglycerid (50 percent) or 
glycerol of tannin to the affected parts if they are 
edematous. Quinin (4 grains) every 3 or 4 hours 
may be administered. If the disease is due to a 
rheumatic tendency, sodium salicylate (7 grains) 
or aspirin is indicated. 
Local Treatment.-Give small pieces of ice on 
the tongue every hour or two; apply at onset of 
symptoms a few drops of a solution of cocain 
(4 percent), and also: 
1$. Menthol, gr. vj 
Almond oil, 3 ij. 
Apply every 3 hours. 
In some cases it is advisable to apply a strong 
solution of silver nitrate (20 grains to 1 ounce) 
during the initial symptoms. If the fever is high, 
phenacetin (5 grains) may be given every 3 
or 4 hours and the aconite discontinued. A 
nutritious fluid diet should be given. 
small reddish or pink granulations composed of 
glandular tissue. The capillaries are highly in- 
jected, and the surface of the mucous membrane 
seems rough and often mottled. The mucous 
secretion is thick, viscid, and very tenacious. Di- 
gestion is bad, and dyspepsia is a frequent accom- 
paniment. 
Atrophic Pharyngitis.-The mucous membrane 
is lighter in color and atrophied. 
Ulcerative pharyngitis is characterized by the 
formation of ulcers, generally of a specific nature, 
such as from syphilis, tuberculosis, or cancer. 
Syphilitic ulcers of the pharynx and tubercular 
ulcers of the pharynx are differentiated by Bos- 
worth as follows: 
Syphilitic Ulcers. 
Deeply excavated. 
Few granulations, and 
those highly inflam- 
matory. 
Deep-red areola. 
Sharply-cut edges. 
Distinct demarcation. 
Yellow purulent secre- 
tion. 
Discharge profuse. 
Penetrating to deeper 
tissues. 
No fever as a rule. 
Tuberculous Ulcers. 
No apparent excavation. 
Much indolent granula- 
tion. 
Faint areola. 
Irregular and ill-defined 
edges. 
Demarcation indistinct. 
Grayish, ropy mucous 
secretion. 
Discharge scanty. 
Superficial, with lateral 
in place of deep ex- 
tension. 
Hectic fever as a rule. 
Suppurative Pharyngitis.-There is a suppura- 
tive inflammatory process, first confined to the 
pharynx, but later extending downward to the 
larynx and trachea, or upward into the nasal 
chamber. The predominant feature is its tendency 
to involve the deeper structures, leading to 
suppuration and sloughing. 
Prognosis depends upon the cause. In the 
atrophic form the disease may be very obstinate 
In the suppurative variety grave complications 
may ensue. 
Treatment. Hypertrophic Pharyngitis.-Cor- 
rect any constipation by the use of Rochelle or 
Epsom salts (2 to 3 drams), taken before breakfast, 
or fluidextract of cascara (1/2 dram) at bedtime. 
A pill composed of aloin, strychnin, and bella- 
donna may be taken 3 times daily. For the in- 
digestion, avoid overloading the stomach, espe- 
cially with rich desserts. Alcohol should not be 
used. Tobacco, tea, and coffee should be re- 
stricted. Give elixir of lactopeptin and gentian 
(2 drams) after each meal. As a general tonic, 
the elixir of the phosphates of iron, quinin, and 
strychnin, after meals, is valuable. In bathing 
it is necessary to guard against taking cold, and 
the time should be so arranged as to exercise this 
precaution. Frequent bathing is essential. To 
render the throat less susceptible, cold water may 
be sponged over parts once or twice daily. The 
habit of constantly clearing the throat should be 
absolutely repressed. 
Local Treatment.-Alkaline sprays should be 
used every 2 or 3 days to keep the parts clean. 
Synonyms.-Clergyman's sore throat; chronic 
follicular tonsillitis. 
Varieties.-(1) Hypertrophic; (2) atrophic; (3) 
ulcerative; (4) suppurative (hospital sore throat). 
Etiology.-(1) Sequel of acute pharyngitis; (2) 
excessive straining of the voice or continuous 
clearing of the throat; (3) constant inhalation of 
dust or tobacco. 
Symptoms and Clinical Course.-The voice is 
hoarse, often quickly fatigued, and may be entirely 
lost; cough is frequent and hacking in character; 
slight pain is complained of on deglutition. There 
is often a sensation of a foreign body lodged in 
throat, with a constant desire to expel it by forced 
effort, and, in some cases, the viscid, tenacious 
mucus may be tinged with blood. 
Hypertrophic Pharyngitis.-The mucous mem- 
brane is swollen, hypertrophic, and covered with 
Chronic Pharyngitis. PHARYNX, EXAMINATION 
PHENACETIN 
For this purpose, an alkaline antiseptic tablet 
(Seiler), dissolved in 3 ounces of water, acts 
admirably. 
Subsequent to the spraying of the throat by the 
alkaline solution, the following local application 
may be made by means of a spray: 
I). Menthol, gr. ij 
Eucalyptol, gr. j 
Liquid vaselin, 3 j. 
The anterior and posterior nares may also be 
cleansed in the same manner, and the local appli- 
cation made. 
Spray for anterior nares to be used cautiously: 
1$. Menthol, gr. j 
Compound tincture of benzoin 5 j. 
Apply the smallest amount possible to parts 
by means of an atomizer, once a week. 
Should the granulations not begin to disappear 
within the first 2 or 3 weeks of treatment, they 
may be touched with the galvanocautery and the 
other local applications be discontinued for a few 
days. Before applying the cautery to parts, the 
latter should first be cleansed with the alkaline 
spray and subsequently swabbed with a solution of 
cocain (4 percent), being careful that none of the 
solution is swallowed, as alarming symptoms have 
sometimes occurred from this accident. In case 
the galvanocautery is not used, an application of 
silver nitrate (20 grains to 1 ounce) may be made 
once a week, or boroglycerid (50 percent) or 
glycerol of tannin used every 3 days. Carbolic 
acid should be used cautiously about the nares, as 
it has been known to produce anosmia. 
Atrophic pharyngitis may result from the hyper- 
trophic form, and should be treated in much the 
same way. The crusts should be cleansed and an 
oily solution used to keep the nares moist. 
Ulcerative pharyngitis should be treated specif- 
ically Locally, iodoform in powder may be 
blown over the parts equal parts of iodoform and 
boric acid may also be used. At certain intervals 
the granulations may be cauterized with molded 
silver nitrate or the same salt in strong solution. 
Suppurative pharyngitis calls for surgical inter- 
ference if abscesses develop. When this com- 
plication does not ensue, prescribe, as a gargle, the 
alkaline solution recommended for the hyper- 
trophic form. Apply cold cloths to throat ex- 
ternally, and give large doses of the tincture of 
ferric chlorid containing quinin. 
PHARYNX, EXAMINATION. Anatomy.-The 
pharynx is that portion of the alimentary canal 
posterior to the nose, mouth, and larynx. It is a 
membranous sac about 4 1/2 inches in length, of 
cone shape, with the apex directed downward. 
The pharynx has 7 openings: Two posterior nares, 
2 eustachian tubes, mouth, larynx, and esophagus. 
On each side of the pharynx and between the 
anterior and posterior palatine folds may be seen 
the tonsils. 
Normal Appearance.-In color it is somewhat 
redder than the mucous membrane of the mouth. 
On the posterior surface may be seen minute 
elevations or follicles. The minute arterial and 
venous blood-vessels are very tortuous and dis- 
tinct, but are occasionally obscured by an excess 
of saliva and mucus. 
Examination of the pharynx may be made with 
either direct or reflected light. In the former in- 
stance the patient should sit facing the strongest 
light possible, and the examination conducted 
either by holding the tongue down with a tongue- 
depressor, or else have the organ grasped between 
the folds of a napkin and drawn forward. If the 
light is insufficient, the room may be darkened, 
and the light from a lamp reflected by means of 
the head-mirror. The posterior nares may also 
be examined at the same time by the use of the 
laryngoscopic mirror. In those cases in which 
there is a hypersensitiveness of the pharynx, and 
in which it is necessary to examine the posterior 
nares, a very small amount of a 4 percent solution 
of cocain may be swabbed over the vault of the 
pharynx. The laryngoscopic mirror should be 
gently heated before being introduced, otherwise 
the moisture from breathing will obscure the image. 
PHARYNX, INJURIES.-See Neck (Injuries). 
PHENACETIN.-A phenol derivative (acet- 
paraphenetidin), the product of the acetylization 
of paraamidophenetol. It occurs in white, glis- 
tening, crystalline scales, or fine, crystalline 
powder, orderless and tasteless, soluble in 70 parts 
of boiling water, in 12 of alcohol, nearly insoluble 
in water. Dose, 5 to 10 grains in powder, tablets 
or cachets, hourly or every two hours, but larger 
doses, have been administered. 
The action of phenacetin is similar to that of 
acetanilid. It is one of the safest of the new 
synthetic antipyretics, yet in sufficiently large 
doses it is as poisonous as any of its analogues. 
In one case 22 1/2 grains, taken by a woman within 
six hours, produced collapse with marked lividity, 
great dyspnea and restlessness, cold perspiration, 
and slightly dilated pupils; in another case 120 
grains were taken in twelve hours without the 
production of any symptoms (Wood). A toxic 
dose causes vomiting, cyanosis, chocolate-colored 
urine, yellow discoloration of the body, leukocytosis, 
and death by respiratory paralysis. In medicinal 
doses it depresses the heart slightly, and does not 
affect the blood or the respiration. It acts more 
gradually than other antipyretics, its maximum 
effect being reached in three or four hours. It 
reduces fever by lessening heat production and 
causes perspiration without producing collapse. 
It is also analgesic and hypnotic, relieving pain and 
inducing sleep. It has been administered with 
benefit, in 2-grain doses with 1/2 grain of citrated 
caffeine at short intervals, for migraine; also in 
epidemic influenza, both as a prophylactic and as 
a remedy. As an antipyretic it is extensively 
employed in phthisis, peritonitis, polyarthritis, 
endocarditis, typhus and typhoid fevers; and as 
an analgesic in vasomotor neuroses, for the lan- 
cinating pains of locomotor ataxia, also in neu- 
ralgia and hemicrania. It is highly praised in 
whooping-cough, rheumatic and other fevers, and 
though slower in action than antipyrin or acetan- PHENOCOLL 
PHENOL 
ilid, it is deemed fully as efficient in reducing 
pyrexia, while usually free from the depressant 
after-effects of the latter agents. It is strongly 
commended as a local antiseptic dressing. 
For neuralgia: 
I). Phenacetin, gr. x 
Citrated caffein gr. v 
Sugar of milk, gr. xx. 
Divide into 10 powders. Give 1 powder 
every 2 hours while the pain exists. 
Incompatibles are: Acids (strong), alkalies 
(strong), chloral hydrate, oxidizers, piperazin, 
phenol, pyrocatechin, salicylic acid. 
PHENOCOLL.-Produced by the interactions 
of phenetidin and glycocoll. P. Hydrochlorid is 
a soluble phenacetin, chemically and medicinally, 
and is distinguished by its comparatively free 
solubility. It is a white, fine powder, incom- 
patible with alkalies, and is given in doses of 5 to 
20 grains 4 times a day. It is best administered 
in capsule. It has decided antipyretic, anti- 
rheumatic, and analgesic powers, is promptly ab- 
sorbed and readily excreted, and reduces fever 
without the marked sweating or other unpleasant 
after-effects of other coal-tar antipyretics. In 
hectic, malarial, typhoid, and other fevers, in acute 
rheumatism, neuralgia, epidemic influenza and its 
neuralgic pains, in gouty and rheumatic affections 
when accompanied by fever and pain, and in com- 
bination with piperazin (15 grains), it has been 
employed with success. P. Salicylate, the salicy- 
late of the synthetic base phenocoll, combines the 
actions and uses of its constituents. Dose, 15 to 
30 grains. 
PHENOL. C8H5OH.-Formerly called carbolic 
acid-is procured from coal-tar by fractional distil- 
lation and subsequent purification, or made 
synthetically. It has a very peculiar and 
characteristic odor, a burning taste, is poisonous 
and has preservative properties. It crystall- 
izes in colorless rhombic needles; and at 
ordinary temperatures it dissolves in water 
with difficulty (1:15), but is soluble in alcohol, 
ether, glacial acetic acid, and glycerin in all pro- 
portions. Upon exposure to light and air it 
deliquesces, and acquires a pinkish color. It is 
used in the manufacture of many of the artificial 
coloring-matters: e. g., picric acid, used as a yellow 
dye. Large quantities of various qualities of 
carbolic acid are consumed for antiseptic pur- 
poses. Dose, 1/4 to 1 grain, well diluted. 
Therapeutics.-Phenol is employed as an anti- 
septic, caustic, and local anesthetic. For anti- 
septic dressings and for purifying sponges, and for 
instruments, it is most useful. In diphtheria, 
infectious stomatitis, or ulcerative sore throat, 
combined with glycerin, it is a valuable applica- 
tion. Internally it is used in acute diarrhea and 
flatulent dyspepsia (1/4 to 1 grain), and as a de- 
odorant inhalant in bronchiectasis, pulmonary 
gangrene, and phthisis. Injections of 3 to 5 
minims of a 2 percent solution will often abort 
carbuncles and boils. It is in common use in 
dentistry as an antiseptic and local anesthetic. 
It will allay the itching in eczema, pruritus, and 
piles, and will check obstinate vomiting from 
gastric irritability. Mixed with vaselin, 5 drops 
to the ounce, it makes a soothing application for 
burns. As a caustic it may be used against con- 
dylomata and chancroids. 
A wash in acne or impetigo: 
1$. Phenol, gr. x 
Glycerin, 
Rose-water, 
each, 3 j. 
In tympanites: 
I|. Phenol, gr. j 
Extract of opium, . gr. j 
Bismuth sub nitrate, gr. xviij. 
Make into 6 powders. One powder 3 times 
a day. 
For mosquito-bites: 
I). Phenol, gr. xxx 
Glycerin, 3 iij 
Rose-water, enough for 3 viij. 
Make into a lotion. 
Poisoning.-A toxic dose of carbolic acid, taken 
internally, is one of the most rapidly acting poisons 
known, sometimes equaling prussic acid in this 
respect. The symptoms develop almost immedi- 
ately, and death may occur in a very few minutes- 
but usually the patient lives from 1 to 10 hours- 
rarely over 2 days. In some cases a great amend; 
ment has occurred, with restoration of conscious; 
ness, but after some hours sudden and fatal collapse 
has supervened. The minimum fatal dose is not 
determined, but 1/2 of an ounce has frequently 
caused death; and doses as small as 6 minims have 
given rise to dangerous symptoms. Cases of 
suicidal and accidental poisoning by this drug 
are very frequent, by reason of the facility with 
which it may be obtained for use as a disinfectant. 
If the patient is seen shortly after ingestion, 
apomorphin may be administered hypodermic- 
ally, as a rapidly acting emetic; but in any case 
the stomach should be washed out freely with 
alcohol and water, equal parts of each, and 8 or 10 
ounces of the same should be left in the stomach 
for a short time, and this is to be followed by a 
washing out with warm water. Next in value is 
any soluble sulphate to form the harmless phenol- 
sulphonates: as, magnesium sulphate 1 ounce or 
sodium sulphate 1/2 of an ounce, dissolved in 
1/2 of a pint of water. Even if several hours have 
elapsed since the ingestion of the poison, the 
sulphates should be used, as their antidotal action 
proceeds in the blood. In one case where 1/2 of 
an ounce of the 95 percent acid had been taken, 
nearly 3 ounces of magnesium sulphate (Epsom 
salts) were used, resulting in complete recovery 
from an apparently hopeless condition. Stimu- 
lants, as ether or brandy hypodermically, should 
be used freely; also hot-water bottles and hot 
blankets if signs of collapse appear. Vegetable 
demulcents may be given (but no oils or glycerin), PHENOLPHTHALEIN 
PHOSPHORUS 
to protect the mucous surfaces. Liquor calcis 
saccharatus or syrupus calcis is also antidotal to 
the poison in the stomach, but is much less effi- 
cient than the sulphates. Atropin hypodermically 
is a very complete physiologic antagonist to the 
systemic symptoms, maintaining the heart and 
respiration until elimination occurs (Post). Oils 
should not be used, as they increase the absorp- 
tion of the poison (Potter). 
Incompatibles are: acetanilid, acetphenetidin 
(phenacetin), antipyrin, albumin, antisepsin, bor- 
neol, bromal hydrate, bromin water, butyl- 
chloral hydrate, camphor, chloralformamid, 
chloral hydrate, collodion, diuretin, ethyl carba- 
mate (urethan), euphorin, exalgin, ferric salts, 
gelatin in dilute solution, hydrogen dioxid, lead 
acetate, menthol, methacetin, naphthol, nitric 
acid, phenyl salicylate (salol), piperazin, potas- 
sium permanganate, pyrocatechin, pyrogallol, 
resorcinol, sodium phosphate, thymol, terpin 
hydrate. 
Preparations.-P. Liquefactum, a liquid com- 
posed of not less than 86.4 percent by weight of 
absolute phenol, and about 13.6 percent of water. 
Dose, 1/2 to 2 minims. Glyceritum P., has of 
liquefied phenol 20, glycerin 80. Dose, 3 to 10 
minims. Unguentum P., has of phenol 3, white 
petrolatum 97. For external use. Sodii Phenol- 
sulphonas (Sodium sulphocarbolate'), occurs in 
transparent, rhombic prisms, soluble in 5 of water. 
Dose, 2 to 10 grains. Zinci Phenolsulphonas 
occurs in transparent, rhombic prisms, soluble in 
2 of water. Dose, 1 to 5 grains. 
PHENOLPHTHALEIN.-A white powder made 
by the interaction of phenol and phthalic anhy- 
drid. It is used as a laxative and purgative. Dose, 
1 to 3 grains. See Constipation. 
PHENOLSULPHONATE.-A salt of phenolsul- 
phonic acid. 
Zinc phenolsulphonate is antiseptic and disin- 
fectant. It is used as an intestinal antiseptic and 
sometimes in small doses for fetor of the breath. 
The phenolsulphonates of sodium and potassium 
are employed internally with advantage in septic 
diseases, the exanthems, diphtheria, puerperal 
fever, etc., with the object of obtaining the anti- 
septic action of phenol without the dangers at- 
tending its use in efficient doses. They may be 
used locally with good results in aphthae, tonsillitis, 
otorrhea, gonorrhea, and for inflamed mucous 
membranes generally. 
PHENOSALYL.-A clear, syrupy liquid, pre- 
pared by fusing together phenol 9 parts, salicylic 
acid 1, lactic acid 2, and menthol 0.1. It has a 
pleasant odor, is very soluble in water, and is used 
in a 1 percent solution as an antiseptic application, 
and in 10 to 30 percent solutions as a curative 
lotion for varicose ulcers and ulcerated gummata. 
It is said to be superior as a germicide to any one 
of its ingredients, and to prove much less toxic 
than the agents usually so employed. 
PHIMOSIS.-See Penis (Diseases). 
PHLEBITIS.-See Veins (Inflammation). 
PHLEBOTOMY.-See Venesection. 
PHLEGMASIA ALBA DOLENS (Milk Leg).- 
An acute swelling of the leg due to venous ob- 
struction from thromboses, and occurring most 
frequently in women after labor. 
Etiology.-It is usually due to some form of 
septic infection of the genital region. Perineal or 
cervical tears may be the point of entrance of the 
poison. Infection of the blood-vessels at the 
placental site is probably the most frequent cause. 
Occasionally it may be due to simple pressure; 
these cases arise usually during the latter part of 
pregnancy. 
Symptoms.-The symptoms usually develop 
from 1 to 3 weeks after labor. The leg becomes 
swollen, firm, and tender on pressure. The skin 
is strongly stretched and white in color; move- 
ment of the leg is extremely painful. There may 
be tenderness and redness over the course of the 
femoral vein. One or both legs may be affected. 
Fever, rapid pulse, and prostration, more or less 
marked, are common accompaniments. In the 
severer cases suppuration and abscess of the cellu- 
lar tissue of the leg may develop. 
Prognosis.-The prognosis depends very largely 
upon the cause of the condition. If it is an accom- 
paniment of a general septic process, it is very 
grave. It is always doubtful, on account of the 
liability to embolism. 
Treatment.-This consists in elevation of the 
leg with absolute rest. It should be well protected 
with cotton, and, if the pain is very severe, hot 
applications or ichthyol ointment may be tried. 
Should abscess occur, free incision and drainage 
are required. The constitutional treatment should 
consist in plenty of good, nutritious food and free 
stimulation. 
PHLYCTENULAR CONJUNCTIVITIS.-See 
Conjunctivitis. 
PHONENDOSCOPE.-An instrument designed 
to be used in place of the stethoscope in ausculta- 
tion. It consists of a shallow metal cup covered 
by a disc of ebonite, with a perforation in the cup 
to which are attached rubber tubes for the ears. 
From the center of the disc of ebonite arises a 
little rod with a button at the end. The tubes are 
placed in the ears, and the button is placed over 
the organ to be examined, while the finger is 
drawn over the skin, beginning at the point where 
the button is applied and running outward. The 
rasping bruit heard before the application of the 
phonendoscope ceases as soon as the finger passes 
beyond the organ. The instrument is useful to 
differentiate murmurs and distinguish between 
endocardial and pericardial sounds. It is a distinct 
improvement over the binaural stethoscope. See 
Chest (Examination). 
PHOSPHORIC ACID. H3PO4.-Orthophos- 
phorie acid. It is said to be of value in strumous 
affections, but is of little real benefit except as a 
feeble digestive stimulant. Dilute phosphoric acid 
contains 10 percent of the absolute acid. Dose, 
5 to 45 minims. 
PHOSPHORUS.-A nonmetallic element, having 
a quantivalence of III or V, and an atomic weight 
of 31. Symbol, P. Phosphorus does not occur^in 
the free state, but is widely distributed in rocks, 
in fertile soils, in animal and vegetable tissues, in 
urine, and in guano. The human body contains a PHOSPHORUS 
PHOTOMICROGRAPHY 
large quantity of calcium phosphate in the form of 
complex organic compounds. Phosphorus is an 
important constituent of nervous tissue. In com- 
merce it is prepared from bone-ash, or from som- 
brerite, an impure calcium phosphate found in 
West Indian guano. Phosphorus may be ob- 
tained in several allotropic forms. Ordinary phos- 
phorus is a yellowish-white, waxy solid, of a specific 
gravity of 1.837. It melts at 44.2° C., and boils 
at 290° C It is insoluble in water, soluble to a 
slight extent in olive oil and in ether, freely in 
carbon disulphid. Red or amorphous phosphorus 
is formed when ordinary phosphorus is heated to 
240° C., in an atmosphere free from oxygen; also 
by the addition of a trace of iodin at 200° C. It is 
a dark red powder, having a specific gravity of 2.11, 
insoluble in carbon disulphid, noninflammable, 
nonluminous, and nonpoisonous. Metallic rhom- 
bohedral phosphorus is an allotropic form pro- 
duced by heating phosphorus in a sealed tube 
with melted lead. Its specific gravity is 2.34. 
Other modifications have been described. Phos- 
phorus combines with other elements to form 
phosphids; with hydrogen and oxygen to form a 
series of acids, known chiefly through their salts. 
Therapeutics.-Medicinally, phosphorus is used 
as an alterative in osteomalacia, rickets, and un- 
united fractures. It is also employed in sexual 
impotence, in threatened cerebral degeneration, 
in neuralgia, and in convalescence from exhausting 
diseases. Dose, 1/150 to 1/50 grain. 
Poisoning.-Ordinary phosphorus is exceedingly 
poisonous; it causes a widespread fatty degenera- 
tion, most marked in the liver. Vomiting is one 
of the earliest symptoms, the material ejected being 
generally luminous in the dark. Jaundice ap- 
pears usually within 36 hours; sometimes, however, 
much later. The liver is at first enlarged, but 
subsequently diminishes in size. Cerebral symp- 
toms of an intense type occur-wild delirium, con- 
vulsions, coma. Death is generally due to failure 
of respiration and circulation. The urine in phos- 
phorus-poisoning is albuminous, contains bile 
acids and pigments, and leucin and tyrosin. 
Chronic phosphorus-poisoning is common among 
workers in match factories. A prominent symp- 
tom is necrosis of the jaws. See Jaws (Diseases). 
The treatment of phosphorus-poisoning consists 
in the administration of emetics and purgatives 
and of the antidote-copper sulphate or old 
French oil of turpentine. 
Preparations.-Acidum Hypophosphorosum, a 
liquid composed of 30 percent by weight of abso- 
lute hypophosphorous acid, H3PO2, and 70 percent 
of water. Acidum Hypophosphorosum Dilutum, a 
liquid composed of 10 percent of the absolute acid 
and 90 percent of water. Used in the preparation of 
Syrupus hypophosphitum. Dose, 5 to 10 minims. 
P. Pilulae, each contain phosphorus 1/100 grain 
dissolved in chloroform, mixed with althaea and 
acacia in glycerin and water, and coated by shaking 
with a solution of balsam of tolu in ether. Dose, 
1 to 2. Calcii Hypophosphis, colorless prisms, or 
thin, pearly scales, of nauseous taste, soluble in 
6.8 of water, insoluble in alcohol. Is an ingredient 
of the syrupus hypophosphitum. Dose, 5 to 15 
grains. Ferri Hypophosphis, a white or grayish- 
white powder, odorless and tasteless, slightly sol- 
uble in water. A ferruginous tonic. Dose, 1 to 5 
grains. Mangani Hypophosphis, a pink, crystal- 
line powder, soluble in water, almost insoluble in 
alcohol. Dose, 1 to 5 grains. Potassii Hypophosphis, 
white masses, or a white granular powder, deli- 
quescent, odorless, of saline taste and neutral 
reaction. Soluble in 0.6 of water and in 7.3 of 
alcohol at 59° F. Dose, 5 to 10 grains. Sodii 
Hypophosphis, small plates, or a white, granular 
powder, deliquescent, odorless, of sweetish, saline 
taste, and neutral reaction. Soluble in 1 of water 
and in 30 of alcohol at 59° F. Dose, 5 to 30 
grains. Syrupus Hypophosphitum has of calcium 
hypophosphite 4 1/2, of potassium and sodium 
hypophosphites 1 1/2 each, percent. Dose, 
1 to 4 drams. Calcii Phosphas Praecipitatus, a 
light, white amorphous powder, insoluble in water 
or in alcohol. Dose, 2 to 30 grains. Syrupus 
Calcii Lactophosphatis has of calcium carbonate 
2 1/2, lactic acid 6, phosphoric acid 3.6, percent. 
Dose, 1 to 4 drams. Sodii Phosphas, large, 
colorless, monoclinic prisms, efflorescent, of 
saline taste and alkaline reaction; soluble in 6 of 
water, in 11/2 of boiling water; insoluble in 
alcohol. Its solubility in water is much increased 
by the addition of citric acid. Dose, 20 grains 
to 2 drams. Sodii Phosphas Exsiccatus is the 
crystallized phosphate allowed to effloresce, and 
then gradually heated to 212° F. until the salt 
ceases to lose weight. Dose, 10 to 20 grains. 
Sodii Phosphas Effervescens has of the exsic- 
cated salt 20, sodium bicarbonate 47 3/4, tartaric 
acid 25 1/4, citric acid 16 1/4. Dose, 1 to 3 drams. 
Liquor Sodii Phosphatis Compositus has of the 
phosphate 100, sodium nitrate 4, citric acid 13, 
wrater to 100. Dose, 1 to 3 drams. Sodii Pyro- 
phosphas, colorless, monoclinic prisms, of saline 
taste and alkaline reaction; soluble in 12 of water, 
insoluble in alcohol. Dose, 10 to 45 grains. Elixir 
Ferri, Quininae Strychninae Phosphatum has 1/64 
grain of strychnin in each dose of 1 dram. Dose, 
1/2 to 2 drams. Glyceritum Ferri, Quininae et 
Strychninae Phosphatum has in each dose of 15 
minims 1/80 grain strychnin. Dose, 10 to 20 
minims. Syrupus Ferri, Quininae et Strychninae 
Phosphatum has in each dose of 1 dram 1/80 
grain strychnin, and is prepared by mixing the 
glycerite 25 with syrup to 100. Dose, 1/2 to 2 
drams. Ferri Phosphas Solubilis, and Ferri 
Pyrophosphas Solubilis are described under Iron. 
For glycerophosphates, see Glycerophosphoric 
Acid. 
PHOTOMICROGRAPHY.-A photograph of a 
small or microscopic object, usually made with the 
aid of a microscope, and of sufficient size for ob- 
servation with the naked eye. A microphoto- 
graph is a microscopic (in size) photograph. 
Apparatus.-Different varieties have been de- 
vised; possibly the simplest consists of a camera 
with extra long bellows length and stable base or 
support upon which the microscope can be clamped. 
Of the different varieties, the horizontal, the 
reversible, and the reversible in a vertical position 
have been described. While sunlight is preferred, PHOTOPHOBIA 
PHOTOTHERAPY 
light derived from a paraffin lamp, incandescent 
gas, magnesium oxyhydrogen, acetylene or electric 
light will do. An apparatus which may be used 
in either the vertical or horizontal position is 
offered by the leading microscope makers in 
America and abroad. A compound microscope 
with larger diameter body tube is preferable. 
The camera is so made that bellows is adjust- 
able at both ends along its supporting bed bar 
attached to the heavy base which supports also 
the microscope in relation to the bellows so that 
the sensitive plate may at all times be kept par- 
allel to the specimen under the microscope whether 
bellows stands vertically, inclined or in a hori- 
zontal position. The double plate carrier is the 
usual 4 by 5 inches size with kits for 3 1/4 by 
4 1/4 plates. Any of the hand camera shutters 
may be used on the front board; a light-tight 
connection is provided between shutter and micro- 
scope tube. Where artificial light is used simply 
the lamp with bull's eye lens separately or in 
combination will do. A more elaborate illumi- 
nating system of lamp and condensers as supplied 
on projection lanterns is used quite often. A 
dark room is necessary only for loading plate 
holders and developing plates after exposure. 
Depending upon the size of the objective and 
character of specimen, also light intensity, expo- 
sures from 1/25 second to 10 minutes are made. 
Practical Manipulation (Crookshank).-For 
working with the paraffin lamp, the mode of pro- 
cedure is, as regards the illumination, briefly as 
follows: The substage condenser, as well as the 
mirror, is dispensed with when a low power is 
employed, and the lamp is so placed that the 
image of the flat of the flame appears accurately in 
the center of the field of the microscope. A bull's- 
eye condenser is then interposed, so that the 
image of the flame disappears and the whole field 
is equally illuminated. With high powers the 
substage achromatic condenser is necessary, and 
a more intense illumination is obtained by using 
the flame edgewise. In using a low power with 
the oxyhydrogen light, the lantern is withdrawn 
some little distance from the microscope. By 
opening and closing the shutter of the camera, 
the plate is exposed usually about 3 seconds. 
Determination of amplification varies with the 
object employed, and also with the distance of the 
focusing screen from the object. To determine 
the amplification afforded1 by a certain objective 
at a certain distance, a photograph should be 
taken, under the same conditions, of the lines of 
the micrometer slide. From this calculate the 
amplification obtained by the photomicrograph. 
PHOTOPHOBIA.-A dread or intolerance of 
light, usually due to some inflammation of the 
eye. It is particularly common in strumous 
children with phlyctenular disease of the cornea. 
It may be present in any inflammatory condition 
of the eye, whether of the conjunctiva, cornea, 
iris, ciliary body, choroid, or retina. In many 
cases it is directly due to uncorrected ametropia. 
In such instances the constant use of tinted glasses 
is most pernicious. Photophobia is often asso- 
ciated with diseases of the nervous system, cerebral 
iritation, meningitis, etc. It is also seen in many 
pyrexial conditions. See Eye. 
" PHOTOTHERAPY (Light Therapy) .-The treat- 
ment of disease by light rays. The beneficent 
effects of light upon the debilitated body have 
long been recognized. Besides the ordinary 
sun-bath, various means of using artificial light 
have been proposed. To the chemic properties 
of the ultraviolet rays are attributed the good 
effects of the electric-light bath. The functions 
of the organism are stimulated without eleva- 
tion of temperature and consequent disturbance 
of circulation. 
At the present time, the term phototherapy is 
more strictly used to designate the treatment of 
skin-diseases and other affections in the manner 
devised by Finsen, of Copenhagen. This investi- 
gator treated the exanthems of small-pox and other 
eruptive diseases by means of red light. As the 
"chemic" (blue, violet, and ultraviolet) rays of 
light are capable of causing an inflammation 
(erythema solare) of the healthy skin, it may be 
assumed that they are equally capable of aggra- 
vating preexisting inflammations. In other words, 
if the diseased skin was protected against the in- 
jurious action of the chemic rays of light, it would 
be possible to diminish the intensity of the inflam- 
mation, and thus prevent suppuration. The ob- 
ject was therefore to exclude the chemic rays of 
light which are injurious to the skin. In a new 
treatment of lupus and other bacterial skin-diseases 
devised by Finsen, these rays are now used as 
curative agents. The method consists in treating 
local superficial bacterial skin-diseases by the con- 
centrated chemic rays of light. Bie, an assistant 
of Finsen, published a description of the method 
and technic, and it is from his paper that the 
material for the present article has been obtained. 
The experimentally proved data on which the 
method is founded are the following: 
1. The bactericidal property of the chemic rays 
of light. 
2. The power of the chemic rays of light to pro- 
duce an inflammation of the skin (erythema 
solare). 
3. The power of the chemic rays of light to pene- 
trate the skin. 
The Bactericidal Property of the Chemic Rays 
of Light. 
The bactericidal property of light, originally 
demonstrated by Downes and Blunt, has more 
recently been studied in detail by a great many 
investigators. The particular question which is 
of the greatest interest in this connection is the 
following: Whether the bactericidal property is 
essentially attached to a single part of the spec- 
trum, or whether it resides only in the whole un- 
colored light. The most trustworthy examinations 
have given the result that it is especially due to the 
blue and violet rays. If it is desired to employ the 
bactericidal property of the light therapeutically, 
the greatest possible number of violet and ultra- 
violet rays must be procured. On the other hand, 
the red, yellow, and green are useless. PHOTOTHERAPY 
PHOTOTHERAPY 
Another condition for the advantageous use of the 
bactericidal property of the light therapeutically 
is that the bacteria are quickly killed. Finsen has 
found that on days of bright sunshine at noon in 
July and August in Copenhagen, the sunlight 
killed the bacillus prodigiosus in plate-cultures 
within 11/2 hours of insolation. An electric arc- 
lamp of 25 amperes killed a plate-culture of the 
bacillus prodigiosus at a distance of 75 cm. from 
the carbon points after 8 to 9 hours' exposure. 
Even the strongest sunlight in summer-which 
takes more than 1 hour to kill the bacteria in 
plate-cultures, and probably still longer when they 
are growing in the skin-has then too slight a 
bactericidal property ever to be of any use for 
therapeutic purposes, otherwise all bacterial skin- 
diseases would be cured spontaneously in the 
summer. In order to obtain a more energetic 
effect, Finsen concentrates the light by means of 
apparatus, which is described later. It is only 
when the light is concentrated in such a way that 
it contains as many blue, violet, and ultraviolet 
rays as possible that its bactericidal property be- 
comes so powerful that it can be used therapeutic- 
ally with advantage. Concentrated electric light, 
which Finsen now uses for the treatment of pa- 
tients, kills the bacteria until now examined in a 
few seconds when they are spread in a stratum of 
agar about 1/5 mm. thick. 
The Power of the Chemic Rays of Light to Penetrate 
the Skin. 
This point has been investigated by Godneff 
and Finsen. With a trocar Godneff placed small 
sealed glass tubes with silver chlorid under the skin 
of dogs and cats. Then he allowed some of these 
animals to remain in the dark, while he exposed 
the rest of them to the direct sunlight. After an 
hour he took out the tubes; and it was invariably 
found that the silver chlorid was blackened in 
those animals exposed to the sun, but not in those 
kept in the dark. The chemic rays of light can 
then penetrate the skin. Finsen thus proved that 
they penetrate far more easily in bloodless tissues 
than those filled with blood. He placed a piece of 
sensitized paper on one side of a man's ear, letting 
the blue and violet rays of one of his apparatus for 
concentration of sunlight fall on the other side of 
the ear. After 5 minutes this paper was not 
affected; on the other hand, the paper was dis- 
tinctly blackened in 20 seconds, if all the blood 
was pressed out of the ear between 2 glass plates. 
In agreement with this is the fact that by looking 
into a spectroscope through an ear filled with 
blood the observer will only discover a red stripe; 
if the ear is made anemic, the spectrum will consist 
of all the colors. Accordingly, the area of the skin 
that is going to be treated is made as anemic as 
possible. 
The Power of the Chemic Rays of Light to 
Produce an Inflammation of the Skin. 
Based as it is on these three experimentally 
proved facts, this method of treatment is so ra- 
tional that objections can scarcely be raised against 
it from a theoretic point of view. In the treatment 
of patients sunlight is used in the summer, when 
the sky is bright, otherwise the light of electric 
arc-lamps of 50 to 80 amperes. As already ex- 
plained, it is only by concentration that the light be- 
comes so powerful that its bactericidal property 
can be used in treatment. In order to avoid burn- 
ing the skin it is also necessary to cool the light. 
This double object-to make the light stronger 
and cooler-is attained, in regard to the sunlight , 
by an apparatus consisting of a lens of about 20 
to 40 cm. in diameter. The lens is composed of a 
plane glass and a curved one, which are framed in a 
brass ring, and between them there is a bright 
blue, weak, ammoniacal solution of copper sul- 
phate. As one surface of the liquid is a plane, the 
other one being curved, its optic function is that of 
an ordinary planoconvex glass lens. By making 
the lens of a blue liquid instead of solid glass, a 
considerable cooling of the light will be obtained, 
because water absorbs the ultrared rays, and be- 
cause the blue color excludes a considerable amount 
of the red and yellow rays. These three kinds of 
rays have particularly strong heating effect, while 
their bactericidal power is insignificant. On the 
other hand, the blue, violet, and ultraviolet rays, 
which it is important to procure in as great a 
number as possible, are but very slightly impaired 
by passing through the blue liquid. The lens 
hangs on a foot, made in such a way that the lense 
can be raised and lowered as well as turned on a 
Description of the Apparatus. 
The old name of erythema solare (erythema cal- 
oricum) proves that this disease was supposed to 
be due to a too intense heating of the skin conse- 
quent on the heat that always is inseparable from 
the light. Widmark (Stockholm) first experi- 
mentally showed the error of this view. He con- 
centrated the electric light into parallel rays by 
means of a lens of quartz, and applied them to the 
skin, after they had passed either through a layer 
of distilled water, which absorbs the ultrared rays 
(dark rays of heat) or through a glass plate, which 
absorbs a large part of the ultraviolet rays. It 
turned out to be immaterial whether the light con- 
tained the ultrared rays or not; on the other hand, 
the absorption of the ultraviolet rays by the glass 
plate prevented completely the appearance of 
the inflammation. The experiments of Widmark 
prove, then, that the ultraviolet rays are of pre- 
dominant importance in regard to producing light 
erythema. Later researches made by Finsen have 
confirmed this, and further he has proved that the 
blue and violet rays have also the power to pro- 
duce the specific photochemic inflammation, but 
in a slighter degree than the ultraviolet rays. It 
is still impossible to decide finally of what import- 
ance this photochemic erythema is in regard to 
treating bacterial skin-diseases with concentrated 
chemic rays of light; but that, at any rate, it is not 
quite insignificant for the treatment of lupus 
vulgaris may well be considered probable, in view 
of the trials made of other methods of treat- 
ment which tend to cause an inflammation of the 
skin. PHOTOTHERAPY 
PHOTOTHERAPY 
vertical and horizontal axis; therefore it is easy to 
place the lens perpendicularly on the sun-rays, 
and at such a distance as to make the light strike 
the area of skin which it is intended to treat. 
The apparatus for concentrating the electric 
arc-light consists of lenses of quartz framed in two 
brass tubes, which can be moved, the one into 
the other, like the two pieces of a telescope. 
if the light got cold through a blue solution. Of 
course, the distilled water between the quartz 
lenses is heated by the absorption of the ultrared 
rays. In order to avoid too much heating 
(boiling), cold ordinary water may be run 
through the mantle surrounding this end of the 
apparatus. 
Four such apparatus for concentrating are fixed 
to an iron ring around each lamp, 
this ring again being fixed to the 
ceiling by 4 iron supporters. The 
lamp is movable up and down by the 
mechanism, and can be put exactly 
into the center of the ring by the aid 
of four strings, which are connected 
with screws in the iron support. The 
apparatus for concentrating hangs on 
iron arms, fastened to the ring, and 
depends from this at an angle of about 
45 degrees, because the lamp sends 
out the strongest light in this direc- 
tion; the apparatus for concentrating 
can be put nearer to or further from 
the lamp by sliding on the iron arm. 
By this disposition the lamp and the 
apparatus for concentrating can be 
fixed so that the points of the car- 
bons are exactly in the focus of the 
front lenses of all the four apparatus. 
The apparatus for concentrating can 
be revolved on a perpendicular axis and a hori- 
zontal one by 3 screws; by this they can be so 
placed that the axis of the apparatus gets 
fused with the axis of the parallel rays, so that no 
light is striking the brass cylinders. The distant 
focus can be placed at the height which suits the 
patient by pushing the lowest cylinder into the 
uppermost one of the concentration apparatus. 
Lenses of quartz are used because this material, 
in a far higher degree than glass, allows the 
ultraviolet rays to pass through. The apparatus 
for concentrating the sunlight may, on the other 
hand, be made of glass, because all the ultraviolet 
rays of the sunlight have so long a wave-length 
that they can pass through glass; those of a 
shorter wave-length are already absorbed by the 
atmosphere. 
In the part of the apparatus which 
faces the lamp, two lenses are placed 
that have together a focal distance of 
12 cm.; when the apparatus is placed 
in such a way that the first lens is 
exactly at this distance from the 
points of the carbons of the lamp, 
they consequently will concentrate 
he divergent rays coming from the 
lamp and make them parallel; these 
rays pass through the brass tubes, 
at the distal end of which they meet 
again with two lenses of quartz, which 
concentrate the parallel rays, making 
them convergent. Between these two 
quartz lenses there is distilled water, 
which cools the light by absorbing the 
intensely heating ultrared rays, but 
does not impair the blue, violet, and 
ultraviolet ones. It is not possible, 
as in the apparatus for the sun, to 
make the water blue in order to cool 
the light further, because the extreme ultraviolet 
rays, which abound in the electric light, may 
well pass the quartz, but get absorbed by the 
blue coloring matters; the advantages of using 
the lenses of quartz would consequently be lost 
Treatment by Sunlight 
Treatment by Electric Light. 
Through the two forms of apparatus for con- 
centrating described, the concentrating and cooling 
of the light are thus affected. But the light is still 
too warm to be applied to the skin without 
hurting it; the skin must therefore be cooled in PHOTOTHERAPY 
PHOTOTHERAPY 
order to avoid burning. This is effected by a 
little apparatus consisting of a plate of quartz and 
a plain convex lens of quartz, both framed in a 
conic brass ring which carries 2 small tubes and 4 
arms; to each arm is fastened an elastic band, by 
means of which the apparatus is pressed against 
the skin. By making cold water run into one of 
the tubes and out of the other one, the skin would 
be cooled to such a degree that it can stand even 
the strongest light. By the pressure which the 
planoconvex quartz lens excites on the skin this is 
made anemic, so that the chemic rays penetrate 
it much better. In this manner an area of skin 
1 1/2 cm. in diameter is treated for 1 hour each 
day. The treated skin reddens and swells, a bulla 
may appear, but necrosis has never been observed. 
The illustrations on the previous page show the ar- 
rangement of the apparatus for treatment. 
when this method of treatment appears to be 
ineffective. 
The principle advantages of the method are, 
besides its reliability, its excellent cosmetic results, 
the infrequency of relapses and their slight extent, 
and that the treatment is painless. The good 
cosmetic result is due to the fact that there is no 
destruction of tissue, healthy or diseased. It is 
for the same reason that the results in respect to 
relapse are so favorable. One may, without harm, 
treat both the diseased tissue and the apparently 
healthy surrounding skin until one is fairly sure 
of having destroyed all the disease-germs. When 
the patient has been treated until there are no dis- 
tinct nodules of lupus to be seen at the moment, 
the treatment is discontinued until the swelling and 
redness of the skin have disappeared, so that it is 
easier to determine whether anything is left of the 
disease or not. If there is nothing visible, the 
patient is still kept under observation. Many 
must, however, be submitted to a second course of 
treatment. Whether the nodules which develop 
are the result of recurrence, or whether they could 
not earlier be recognized as lupus nodules, is a 
matter of little consequence in itself. The princi- 
pal thing is that there have always until now been 
a few scattered nodules, which disappear after a 
short further course of treatment. If the treat- 
ment is carried on for some time after the last 
nodule of lupus seems to have disappeared, recur- 
rence would be more surely guarded against. The 
fact that the treatment is discontinued as soon as 
it is thought justifiable to do so, is due solely to 
the wish to save the time and the money of the 
patients as far as possible. Inasmuch as the 
efficacy of the treatment is absolutely certain, and 
the patients, on account of its painlessness, are 
very willing to submit themselves to a second 
course, a recurrence is not nearly so serious a mat- 
ter as it is after the older methods of treatment. 
Lupus Erythematosus.-The treatment of this 
disease has in many cases given excellent results- 
permanent recovery and firm scars. Nevertheless, 
the effect of the treatment is not nearly so sure as 
it is in the case of lupus vulgaris. A few cases 
have improved very slowly and with a constant 
tendency to recurrence. What the cause of this 
great individual difference may be it is still im- 
possible to determine, if for no other reason, 
because we have not a sufficiently great material 
(altogether only 28 patients). 
Alopecia Areata.-As the indication for the treat- 
ment by concentrated chemic rays of light is that 
the disease must be superficial, local, and bacterial, 
and as it is at least possible that alopecia areata is 
due to an infection, Finsen has tried to treat this 
disease. In January, 1899, when the first experi- 
ments were published in Danish, 7 cases in all had 
been cured. 
On the whole, the trials made until now look 
promising. Whether all the fresh cases will give 
results as satisfactory as in those described can be 
solved only by further experiments. To judge 
from the later experiments, even the old decalvans 
form seems to be curable, though only after a long 
treatment (Bie). 
Finsen has tried to treat different skin-diseases, 
known or supposed to be of microbic origin, but it 
is only of lupus vulgaris, lupus erythematosus, 
and alopecia areata that he has treated a number 
of cases sufficiently great to estimate the value of 
the method. 
Lupus Vulgaris.-Up to the time of publication 
of the first edition of this work about 350 cases of 
this disease altogether had been treated. The 
first patients were treated entirely by light; the 
same thing is done with all the slighter cases; on 
the other hand, in the more serious cases the treat- 
ment by light is assisted by treatment with pyro- 
gallic acid ointment in order to make the skin 
smooth and as easily penetrable by the light as 
possible. While one part is being treated by 
light, the pyrogallic acid ointment is put on another 
part; when the cauterization is healed by a zinc 
ointment, this area of skin is treated by light; this 
treatment with ointment is not necessary for ob- 
taining a good result, but it saves much time for 
the patient. All ulcerations are kept free from 
crusts by a cataplasm of a boric acid solution. 
The mucous membranes are touched with a solu- 
tion of iodin and potassium iodid (1:2:2), or are 
treated with the galvanocautery. Only the skin, 
the hard palate, the front part of the septum nasi, 
tongue, and the mucous membrane of the cheek 
have been healed by this method. 
In none of the cases was the treatment without 
effect, but in about 5 cases the improvement was 
very slow, either because the disease was progress- 
ing so rapidly that it was extending in one place 
while the treatment went on in another, or because 
the lupus was so deep that the light could only 
with difficulty penetrate to it. In all the 350 other 
cases the result of the treatment has been satisfac- 
tory. Of course, it takes some time-until all 
the diseased tissue is thoroughly treated and the 
formation of scar tissue has begun-before any 
improvement is visible; but from the moment it 
begins it is continued without interruption until 
the last nodule of the lupus patch has disappeared. 
In all these 350 cases this result was so certain 
and so constant that there is even reason to doubt 
the accuracy of the diagnosis of lupus vulgaris 
Results of Treatment. PHOTOTHERAPY 
PHYSOSTIGMA 
Roentgen rays have been used in same manner 
and for conditions similar to those treated by 
Finsen, as well as for epithelioma. 
kill tubercle bacilli in the larynx or in the lungs by 
transmitted light, as some American physicians 
have proposed doing. 
Therapeutic Effects.-(1) Finsen's treatment 
of small-pox with red light is based on this, that 
by the exclusion of the inflammatory influence of 
the chemic rays on the skin the formation of pus 
in the vesicles and also secondary fever and pocks 
are prevented. (2) The treatment of other exan- 
thematous diseases by red light has not yet been 
thoroughly investigated. Bachmann and Chat- 
iriere have obtained favorable results in the treat- 
ment of measles, and Krukenberg in the treatment 
of erysipelas. (3) The incandescent sweat-baths 
constructed by Kellogg must be considered as 
nothing more than sweat-baths which have no 
specific effects. In this connection, however, 
there seems to be unity of opinion that they are the 
most complete of all sweat-baths. (4) The local 
illumination by incandescent or arc-lamps, made 
by various Russian physicians, especially Minin, 
have no claim on our attention. (5) The general 
light therapy of the future will undoubtedly be 
sun-baths without subsequent packing, or electric 
arc light-baths 150 to 200 amperes with sweating. 
We know at present too little of the general effect 
of light for us to be able to fix definite indications. 
(6) The only local application whose efficiency 
has been proved is Finsen's treatment of skin- 
disease with concentrated chemic light-rays. 
The excellent cosmetic results obtained are to be 
ascribed to the fact that the method is the most 
complete imaginable; nothing is destroyed; there 
is no shrinking; the scars are white and smooth; 
also, as the result of this treatment, not only can the 
diseased tissues be treated, but the contiguous 
sound tissues as well; in this way danger of recur- 
rence is lessened; the treatment is painless; the 
curative effect is remarkable. In 640 patients the 
treatment had to be stopped on account of bad 
results in only 1.7 percent while 85 percent show an 
absolutely favorable result. Only in the case of 
15 percent was the improvement so slow that the 
result could be considered as less favorable. The 
recurrent conditions are favorable under the 
treatment. In lupus erythematosus the results 
were somewhat uncertain. In alopecia areata, 
nsevus vascularis, acne vulgaris, acne rosacea, and 
epithelioma cutaneum very favorable results were 
obtained, especially when it is considered that the 
cases were almost always severe, such as could be 
cured by no other treatment. 
PHTHISIS.-See Tuberculosis. 
PHYSOSTIGMA (Calabar Bean; Ordeal Nut).- 
The seed of P. venenosum, native of West Africa. 
The properties of the drug depend upon 2 alka- 
loids, physostigmin or eserin, C15H21N3O2, which 
paralyzes the motor functions of the spinal cord 
and stimulates muscle-fiber, and calabarin, which 
acts similarly to strychnin. Physostigma should 
contain not less than 0.15 percent of alkaloids 
soluble in ether. Dose, 1 to 3 grains. Applied 
locally to the eye, physostigmin causes contraction 
of the pupil and diminishes intraocular tension. 
On account of its action on muscles it causes in- 
creased peristaltic movements of the intestines. 
Light Cabinets. 
These are closed wooden compartments, in 
which the patient sits or stands, allowing only 
the head to protrude. Upon the inside of this 
cabinet is distributed a number of incandescent 
lamps (25 to 100). 
All observers probably agree that the light 
cabinet is one of the best forms of sweat-bath, in 
that the perspiration breaks out more quickly and 
at a lower temperature than in other baths. Fol- 
lowing the artificial sweating process there is a 
reduction in blood-pressure. The indication for 
treatment may be judged by these two physio- 
logical processes. 
High power incandescent lamps consist of 
incandescent lamps of 300 to 600 candle power 
surrounded by reflectors which cause the rays to 
cross at certain points, or areas of intensification. 
They are used with a fair degree of success in the 
treatment of eczema, pruritis, impetigo, nevus, 
ichthyosis, herpes simplex, herpes zoster, tinea, 
psoriasis, carbuncle, acne, furunculosis, etc. 
For the treatment of the above conditions the 
light from these lamps is brought close enough to 
produce a destructive effect, or far enough away 
to obtain only a stimulant effect. In the former, 
the surrounding tissues are protected by asbestos. 
The applications vary from a few seconds to 
15 or 20 minutes. 
These lamps are also used for the relief of painful 
conditions about the joints and muscles. The 
effect is due chiefly to the heat. 
Conclusions. 
A more recent critical review by Bie leads him 
to the following conclusions: 
Biologic Effects.- (1) The chemic rays, except 
the red, yellow and green can cause a burn of the 
skin (Bouchard, Widmark and Finsen). (2) The 
ultraviolet rays cause an enlargement of the 
cutaneous vessels which may last at least five or six 
months. (3) There is nothing to show that light 
has any influence upon the quantity of hemoglobin 
in the blood. (4) The assertion of Moleschott and of 
others that light increases the excretion of carbon 
dioxid cannot be counted as proved. (5) Chemic 
rays of light have an exciting influence on lower 
animals, light has probably a similar exciting 
influence on men; according to some investigators 
red light has an exciting effect and the violet rays 
have a quieting influence on psychic processes, a 
property which has been made use of with success 
for quieting maniacal patients. (6) The red light- 
rays can penetrate the organism deeply; the blue 
and violet rays can only penetrate the tissues when 
they are bloodless; the ultraviolet rays cannot 
penetrate farther than the superficial layers of the 
skin. (7) The same is true of the power of light to 
kill bacteria in the organism, a power which per- 
tains almost exclusively to the chemical rays, 
having, therefore, curative effect only on superficial 
affections; there can therefore be no use trying to PHYTOLACCA 
PILLS 
In toxic doses death is produced by failure of 
respiration. 
Its therapeutic uses are: In diseases of the eye, 
as in glaucoma and in iritis, to contract the pupil, 
and, alternated with atropin, to break up adhe- 
sions after iritis; in convulsive diseases, as tetanus 
and strychnin poisoning; in constipation from 
atony of the intestines; in bronchitis and dyspnea, 
from weakness of the bronchial muscles. It is 
also used as an antidote to atropin and to strychnin. 
For poisoning give an emetic and inject atropin. 
In tetanus: 
1$. Extract of physostigma, gr. iij 
Powdered ginger, gr. vj. 
Make 6 pills. One pill every hour. 
To procure sleep in delirium tremens: 
I}. Tincture of physostigma, nt xx 
Water, 5 j. 
To be taken at one dose. 
Preparations.-Extractum Physostigmatis, an 
alcoholic extract, of which the usual dose is 1/16 
to 1/4 grain, but 1 to 4 grains are used in tetanus. 
Tinctura Physostigmatis, 10 percent. Dose, 5 to 
20 minims. Physostigminae Salicylas, eserine 
salicylate, colorless, columnar crystals, of bitter 
taste and neutral reaction, soluble in 150 of water 
and in 12 of alcohol. Dose, 1/100 to 1/30 grain. 
Physostigminae Sulphas, eserine sulphate, a white, 
microcrystalline powder, of bitter taste, very deli- 
quescent in moist air, very soluble in water and in 
alcohol. Dose, 1/100 to 1/30 grain. See Eserin. 
PHYTOLACCA.-The dried root of P. decandra. 
It contains a neutral principle, phytolaccin, and an 
acid, phytolaccic acid, also tannin, starch, fixed oil, 
etc. Dose, as an alterative, 1 to 5 grains; as an 
emetic, 10 to 30 grains. It is an emetic, cathartic, 
and motor depressant. Toxic doses cause death 
by paralysis of the organs of respiration. Its 
action is antagonized by alcohol, opium, and 
digitalis. It is serviceable in chronic rheumatism, 
mastitis, tonsillitis, malignant tumors, eczema, 
and similar skin affections. It has also been used 
as a remedy for obesity. Fluidextract of Phyto- 
lacca. Dose, as an alterative, 1 to 4 minims; 
as an emetic, 10 to 30 minims. 
PICA.-The craving for unnatural and strange 
articles of food: a symptom present in certain forms 
of insanity, in hysteria and chlorosis, and during 
pregnancy. Pica is especially urgent during the 
first 2 or 3 months of pregnancy. It is popularly 
known as "longings" or "pinings." In excep- 
tional cases it may amount to insanity, and 
injurious substances-sometimes very disgusting 
ones-are eagerly partaken of. Regulation of the 
digestive tract, combined with moral suasion and 
some mental diversion, are about all that can be 
tried in the way of treatment. With the end of 
pregnancy the condition ceases. 
PICRIC ACID, carbozotic acid, trinitro-phenol, 
C8H2OH(NO2)3, occurs in yellow scales which are 
soluble in 75 of water. Externally it is antiseptic, 
analgesic, coagulant, and in solution is nonirritant 
.to the tissues, but is too corrosive for internal use. 
A saturated aqueous solution is highly recom- 
mended as a local application in erysipelas and 
burns, and is an efficient test for albumin in the 
urine. Ammonium picrate has been credited with 
antiperiodic and anthelmintic powers, and is highly 
praised in pertussis and in exophthalmic goiter, in 
doses of 1/8 to 1/2 grain thrice daily. 
PILES.-See Hemorrhoids. 
PILLS (Pilulae).-Spherical masses composed of 
medicinal agents and intended to be swallowed 
whole. The mass consists of the active ingredients 
and the excipient, the latter being the substance 
which gives the mass its adhesive and plastic 
qualities. 
There are 14 official pills: 
Title. 
Constituents. 
Dose. 
Pilulje: 
Aloes 
Purified aloes and soap, 
each 13 gm., in 100 
pills. 
As a laxative, 
1, 2, or 3 pills 
at bedtime; as a 
purge, 5 rills' 
Aloes et Ferri.... 
Purified aloes, iron sul- 
phate and aromatic 
powder, each 7 gm.; 
confect, rose, q. s., in 
100 pills. 
2 pills. 
Aloes ot masti- 
ches (Lady Web- 
ster dinner pills). 
Purified aloes, 13 gm.; 
mastic, 4 gm.; red 
rose, 3 gm.; in 100 
pills. 
2 pills. 
Aloes et myrrh®.. 
Purified aloes, 13 gm.; 
myrrh, 6 gm. aromatic 
powder, 4 gm.; syrup, 
q. s. 100 pills. 
From 3 to 6 
pills. 
Asafoctid® 
Asafetida 20 gm.;soap, 
6 gm.; 100 pills. 
Compound extract of 
colocynth, 80 gm.; 
calomel, 60 gm.; jalap 
(resin), 20 gm.; gam- 
boge, 15 gm.; 1000 
pills. 
3 pills 
Cathartic® com- 
posit®. 
2 pills. 
Cathartic® vege- 
tabiles. 
Compound extract of 
colocynth, 60 gm.; 
extract hyoscyam., 30 
gm.; resin of jalap, 20 
gm.; extract leptandra, 
15 gm.; resin podo- 
phyllum, 15 gm.; oil 
of peppermint, 8 c.c. 
in 1000 pills. 
2 pills. 
Ferri carbonatis 
(Ferruginous 
pills, chalybeate 
pills. Blaud's 
pills.) 
Ferrous sulphate, 16 gm; 
potassium carbonate, 
8 gm.; sugar, 4 gm.; 
tragacanth, 1 gm.; al- 
th®a, 1 gm.; glycerin 
and water, q. s. in 
100 pills. 
2 pills. 
Ferri iodidi 
Reduced iron, 4 gm.; 
iodin, 5 gm.; powdered 
glycyrrhiza, 4 gm.; 
sugar, 4 gm.; ext. gly- 
cyrrhiza, 1 gm.; 
acacia, 1 gm.; q. s. 
each water, balsam 
tolu, and ether. (See 
U. S. P.) 
2 pills. 
Laxativ® com- 
posit®. 
Aloin, 1.30 gm.; strych- 
nin, 0.05 gm.; extract 
belladonna leaves, 0.80 
gm.; ipecac, 0.40 gm.; 
glycyrrhiza, 4.60 gm.; 
syr., 100 pills. 
2 pills. 
Opii 
Powdered opium, 6.5 
gm.; soap, 2.0 gm.; 
100 pills. 
1 pill. PILOCARPUS 
PIPER 
Title. 
Constituents. 
Dose 
Pilulb: 
Phosphori 
Phos. ,0.06 gm.; althaa, 
6.00 gm.; acacia, 3.00 
gm.; phosphorus dis- 
solved in chloroform, 
and made into a pill 
with about 4 c.c. of a 
mixture of 2 vol. gly- 
cerin, 1 vol. water. 
Coated with 10 gm. 
balsam of tolu dis- 
solved in 15 c.c. ether. 
1 pill. 
Podophylli, bella- 
donna et cap- 
sid. 
Resin podophyllum, 1.6 
gm.; extract of bella- 
donna leaves, 0.8 gm.; 
capsicum, 3.2 gm.; 
sugar of milk, 6.5 gm.; 
acacia, 1.6 gm.; gly- 
cyrrhiza syr. q. s. 100 
pills. 
1 pill. 
Rhei composita.. 
Rhubarb, 13 gm.; aloes, 
10 gm.; myrrh, 6 gm.; 
oil of peppermint, 0.5 
gm., in 100 pills., 
2 pills. 
Preparations.-Fluidextractum Pilocarpi, Dose, 
10 to 45 minims. Pilocarpinae Hydrochloridum, 
white, transparent crystals, deliquescent in the air, 
very soluble in water or alcohol. Dose, 1/8 to 1/2 
grain. Pilocarpinae Nitras, white, shining crystals, 
permanent in the air; soluble in 4 of water and in 
60 of alcohol. Dose, 1/8 to 1/2 grain. 
PIMENTA (Allspice).-The immature fruit of P. 
officinalis. It contains an aromatic, pungent, 
volatile oil that is much used as a flavor and condi- 
ment. It is useful in flatulence and to prevent 
the griping of purgatives. Dose, 10 to 40 grains. 
P., Oleum. Dose, 2 to 5 minims. 
PIMPLES.-See Acne. 
PINEAL EXTRACT.-The pineal gland is pres- 
ent during the entire life of the individual, and its 
removal in animals has been followed by struc- 
tural changes in the central nervous system. It is 
thought that the substance of this gland may act 
remedially in organic and functional affections of 
the brain attended with failure of cerebral nutri- 
tion, as chronic softening, chronic mania, and 
dementia. See Organotherapy. 
PINEAL GLAND.-See Pineal Extract. 
PINGUECULA.-A small yellowish growth on 
the bulbar conjunctiva, close to the cornea, and 
usually to the inner side. It has no vascular 
supply, and is pale when the rest of the conjunc- 
tiva is congested. Mechanical irritation is the 
probable cause. There is little discomfort; al- 
though it may lead to pterygium no interference 
is necessary. 
PINK EYE.-See Conjunctivitis (Acute con- 
tagious). 
PINKROOT.-See Spigelia. 
PIPER (Pepper).-The dried, unripe fruit of P. 
nigrum. It contains a base, piperin, which is 
official, also a green, acrid, concrete oil, abalsamic, 
volatile oil, starch, lignin, gum, extractive, etc. 
Dose, 5 to 20 grains. 
Oleoresina Piperis, oleoresin of pepper, contains 
almost all the volatile oil and acrid resin extracted 
by acetone, with but little of the piperin. Dose, 
1/4 to 1 grain. 
Piperina, piperin, a feeble base obtained from 
pepper, and other plants of the piperaceae. Occurs 
in colorless or pale-yellowish prisms, of neutral reac- 
tion, almost insoluble in water, slightly so in ether, 
but soluble in 30 of alcohol. Dose, 1 to 10 grains. 
Pepper when applied to the skin acts as an irri- 
tant, internally its effects are similar to those of 
other aromatics, being a warm carminative and 
stimulant, increasing slightly the action of the 
heart, stimulating the kidneys somewhat, and ton- 
ing up the mucous membrane of the urinary and 
intestinal passages, by which channels it is elimi- 
nated. It has been thought to possess antiperiodic 
power, and was formerly much employed in inter- 
mittents. Its chief medicinal use is to correct 
flatulence, and to excite action of the stomach, 
being very commonly taken as a condiment with 
food. It is occasionally employed in gleet, but 
more extensively in hemorrhoids and other dis- 
eases of the rectum. Its active constituents are 
the concrete oil or resin and the volatile oil, piperin 
having very slight action on the system except as 
PILOCARPUS (Jaborandi).-The leaflets of Pilo- 
carpus jaborandi or of P. microphyllus, yielding not 
less than 1/2 percent of alkaloids. They contain 
the alkaloids pilocarpin, a syrupy fluid, slightly 
soluble in water, and forming salts; jaborin, iso- 
meric with pilocarpin, but antagonistic thereto in 
action, and does not form crystallizable salts; pilo- 
carpidin, which acts like pilocarpin; also a volatile 
oil, which consists chiefly of pilocarpene and a 
peculiar acid. Dose, 10 to 45 grains. 
Therapeutics.-Pilocarpin stimulates the periph- 
eral ends of the secreting nerves going to glands, 
perhaps also the centers. It thus causes an 
increased flow of the saliva, marked sweating, 
secretion of tears, of mucus from the nose and the 
bronchi; of the gastric and intestinal juices. It 
also stimulates involuntary muscle. On the vagus 
it acts as a stimulant, causing slowing of the pulse; 
in large doses it paralyzes the vagus. Vomiting is 
produced by jaborandi and sometimes by pilocar- 
pin alone. Pilocarpin causes contraction of the 
pupil. Its action is antagonized very completely 
by atropin. Therapeutically, pilocarpin is used 
chiefly in renal dropsy to produce sweating; also in 
uremia, for the same purpose. It probably causes 
an elimination of urea and other waste products, 
both in the sweat and in the saliva. As a dia- 
phoretic it is also employed in coryza and bronchi- 
tis. It has been used most successfully in erysipe- 
las. It may abort the paroxysms of malarial 
fever, but it is not to be employed in asthenic 
fevers, as typhoid. In pleurisy with effusion, in 
catarrhal jaundice of persistent type, in some 
forms of profuse sweating, and in stimulating hair 
lotions, it is serviceable. In small doses pilo- 
carpin has been used in tobacco and alcoholic 
amblyopia. Early in erysipelatous inflammation 
it may be injected around the border-line of the 
area of inflammation. 
For baldness: 
3. Fluidextract of pilocarpin, 3 j 
Tincture of cantharides, 3 ss 
Soap liniment, 3 jss. 
Apply locally once daily. PIPERAZIN 
an antiperiodic and antipyretic, qualities which 
it certainly possesses. 
PIPERAZIN.-A synthetical basic compound 
formed by the action of ammonia upon ethylene 
bromid or chlorid; it occurs as a white, crystal- 
line powder, soluble in water and liquefying when 
exposed to the air, from which it absorbs water and 
carbon dioxid. Dose of the base or its hydro- 
chlorid, 5 to 15 grains. It may be injected 
hypodermically in 3 to 5 percent solution. 
Incompatibles are: acetanilide acetphenetidin 
(phenacetin), alkaloidal salts, alum, butyl-chloral 
hydrate, chloral hydrate, copper sulphate, ferric 
chlorid, ferrous sulphate, mercuric chlorid, phenol, 
phenocoll, picric acid, potassium permanganate, 
quinin, silver nitrate, solution of arsenic and mer- 
cury iodid, sodium salicylate, spirit of nitrous 
ether, tannic acid. 
It forms with uric acid a soluble compound, is 
nontoxic, devoid of physiologic effects, and well 
borne for prolonged periods. It is used in gout, 
for the prevention of renal and vesical calculi in 
the uric acid diathesis, to allay the pruritus from 
uric acid diathesis, and the irritation of the bladder 
from an excess of uric acid. The usual dose of 15 
grains is best given by dissolving this quantity in 1 
pint of water, and having the patient drink a wine- 
glassful of this solution frequently through the day. 
It should not be given in pill nor in powder form. 
It is patented, and sold at a high price. 
PIPERIN.-See Piper. 
PIPSISSEWA.-See Chimaphila. 
PIRQUET'S (von) TEST.-See Tuberculosis. 
PITCH (Pix).-A resinous exudation from the 
stems of certain trees of the genera Pinus (pines) 
and Abies (firs and spruces), and may also be 
obtained as a residue of the distillation of tar. 
Its chief constituents are resin and a volatile oil 
which is a mixture of several isomeric terpenes in 
varying proportions. The only official form is Pix 
Liquida, tar, a product obtained by the destruc- 
tive distillation of the wood of Pinus palustris 
and other species of Pinus. It is thick, viscid, 
semi-fluid, blackish-brown, of acid reaction, tere- 
binthinate odor, and sharp, empyreumatic taste; 
slightly soluble in water, soluble in alcohol, in oils 
and in a solution of potassa or of soda. Its prin- 
cipal constituents are oil of turpentine, creosote, 
phenols, pyrocatechin, acetic acid, acetone, xylol, 
toluol, methylic alcohol, and resins. By distilla- 
tion it yields an acid liquor, pyroligneous acid, 
and an empyreumatic oil, the residue being pitch. 
Dose, 5 to 20 grains, in pill, up to 2 drams daily. 
It is a stimulant to the skin, and is chiefly used 
locally in skin-diseases, especially those of a scaly 
nature, such as psoriasis; internally it is of service 
in chronic bronchitis. 
Pix Burgundica, Burgundy pitch, the prepared 
resinous exudation of Abies excelsa, the Norway 
spruce, a native of Europe and Northern Asia. It 
occurs in hard, brittle, opaque or translucent 
masses, with a shining, conchoidal fracture, almost 
entirely soluble in glacial acetic acid; is very 
fusible, and at the body-heat it softens and be- 
comes adhesive. It is mildly stimulant to the skin, 
and is used as a basis for plasters. Oleum Picis 
PITYRIASIS RUBRA PILARIS 
Liquidae, oil of tar, a volatile oil distilled from tar. 
Dark, reddish-brown (almost colorless when fresh), 
of tarry odor and taste and acid reaction, readily 
soluble in alcohol. Contains a great variety of 
compounds, including cresols, guaiacol, phenol, 
xylol, toluol, pyrocatechin, methylic alcohol, and 
acetone. Dose, 1 to 5 minims. Syrupus Picis 
Liquidae, syrup of tar, has of tar 1/2 percent; and 
is a sweetened tar-water. Dose, 1/2 to 2 drams. 
Unguentum Picis Liquidae, tar ointment, contains 
of tar 50 parts, yellow wax 15, lard 35. Is irri- 
tating unless mixed with finely levigated chalk. 
In eczema (dry, scaly): 
I|. Solution of coal-tar, 
Solution of lead sub- 
acetate, 
each, 5 j 
Water, enough to make 3 vj. 
Use as a lotion. 
Or the following, in hemorrhoids: 
1$. Pitch, 5 j 
Powdered acacia, 5 ss. 
Make into 20 pills. Give 2 pills every night. 
PITUITARY EXTRACT.-The complete removal 
of the pituitary body (or gland) gives rise to symp- 
toms which occur in a definite order, beginning with 
lowered temperature and loss of appetite, then 
twitchings, tremors and nervous phenomena, and 
finally dyspnea and death. Many of these symp- 
toms have abated considerably after the admin- 
istration of pituitary gland substance or an 
extract thereof. This organ has been found 
enlarged in cases of myxedema in which the thy- 
roid was functionally absent, and other observa- 
tions point to some connection between it and the 
disease known as acromegaly. Internally admin- 
istered it causes increase of the cardiac force, and 
a rapid rise of blood-pressure due to direct con- 
traction of the vessels and slowing of the pulse; 
also increased elimination of phosphates without 
corresponding increase of the nitrogenous elements. 
It has been administered with the view of reestab- 
lishing perverted brain nutrition and function, also 
with the object of supplying tone and structural 
growth to the entire nervous and muscular systems, 
on which its secretion seems to act as an alterative. 
Of 13 cases of acromegaly treated with pituitary 
preparations 7 showed varying degrees of improve- 
ment, 5 none, and 1 became worse. In 2 cases the 
violent headache and neuralgic pains in the limbs 
were diminished, and in one case decrease of the 
affected extremities occurred (Kinnicut). It has 
been tried in epilepsy, but with no benefit, and 
there is no condition known in which it is of thera- 
peutic use (Wood). 
PITUITARY GLAND.-See Pituitary Eytract. 
PITYRIASIS.-A term formerly applied to vari- 
ous pathologically dissociated skin affections, the 
most striking clinical feature of which is the pres- 
ence of fine, branny desquamation. Also a syno- 
nym of Seborrhea (q. v.). See Dermatitis, 
Lichen Ruber, etc. 
PITYRIASIS CAPITIS.-See Eczema Sebor- 
RHOICUM. 
PITYRIASIS RUBRA PILARIS.-A rare skin PLACENTA PREVIA 
disease, a hyperkeratosis, closely resembling 
Lichen Ruber (q. v.) but differing from that 
disease in the absence of systemic disturbance, in 
the paler color of the lesions, in the absence, prac- 
tically, of itching and atrophic changes, and in the 
fact that it is not amenable to arsenical treatment. 
PLACENTA PR .ZE VIA.-The attachment of the 
placenta to any part of the lower uterine segment. 
It occurs once in about 1500 cases. 
Varieties.-Four varieties of placenta praevia are 
described, dependent upon its relation in situation 
to the internal os. These are named central, par- 
tial, marginal, and lateral. 
Causes.-These are obscure, the most probable 
being that it is caused by a low insertion of the 
ovum, this being due to a preexisting endometritis. 
It is three times as frequent in multiparae as in 
primipane. 
Symptoms.-The one symptom of placenta 
prae via is hemorrhage. The time of its appearance, 
the amount, and the frequency are largely depend- 
ent on the variety. In the central variety the 
bleeding may occur as early as the third month, 
and may recur so frequently and profusely as to 
cause speedy death. In the lateral variety hemor- 
rhage may not appear at all. Usually there will 
be a slight, painless hemorrhage during the latter 
half of pregnancy, which is followed, as the woman 
approaches term, by others which appear at de- 
creasing intervals and in increasing amounts. 
Physical Signs.-Before the os is dilated, the cer- 
vix is found particularly soft and large, and the 
presenting part is felt through the vaginal vault as 
though separated from the examining finger by a 
thick cushion or pad. After the os is dilated, the 
rough, maternal surface of the placenta is felt in 
striking contrast to the smooth, elastic membranes. 
Prognosis.-This is grave for both mother and 
child. In general practice the maternal mortality 
is about 30 percent. Repeated loss of blood dur- 
ing pregnancy and at labor, lessened vitality, and 
low situation of the placental site, favoring sepsis, 
are all unfavorable factors. The infant mortality 
is about 60 percent. Asphyxia, hemorrhage, and 
accidents during delivery are accountable for this 
high death-rate. 
Treatment.-The treatment of placenta prae via 
will depend upon the severity of the hemorrhages, 
and upon the time at which they make their 
appearance. 
If the bleeding occurs early in pregnancy; if it is 
slight in quantity; and if it is not repeated too fre- 
quently, rest in bed and the administration of 
opium suppositories, 1 grain of the aqueous extract 
3 times daily will be sufficient. Should the bleed- 
ing continue or increase in quantity, a firm tampon 
of iodoform gauze must be introduced into the 
vagina. This usually leads to abortion or miscar- 
riage, and its subsequent treatment is the same as 
that described under Abortion (q- V-Y 
Should the patient pass successfully the seventh 
month of gestation, and should serious hemorrhage 
now occur, the induction of premature labor by 
rapid dilatation of the cervix and combined version 
are indicated. The patient is anesthetized, and 
the vulva and vagina are thoroughly cleansed. 
PLAGUE 
The operator introduces his right hand, made 
aseptic, into the vagina; the cervix is rapidly 
dilated until 2 or 3 fingers may be introduced into 
the uterus, when a foot is grasped and the child 
extracted to the knee. This allows the soft 
breech of the child to lodge in the lower uterine 
segment, where it exerts sufficient pressure upon 
the placenta to prevent free bleeding, and at the 
same time does not interfere materially with the 
exchange of blood between mother and child. 
Labor pains now appear, and the subsequent 
treatment is the same as in an ordinary breech 
presentation. 
Should the operator feel incapable of performing 
version, or should the patient be seen in the midst 
of a most alarming hemorrhage, when further loss 
of blood might seriously endanger her life, the 
most effective treatment is a large antiseptic 
vaginal tampon. This usually excites labor pains, 
and the tampon is expelled before the advancing 
head. Should it fail to do this, the tampon will 
have to be renewed occasionally, until the os is 
dilated sufficiently to effect easy delivery. 
The treatment at term is the same as that pre- 
viously described-either combined version or a 
large vaginal tampon. The latter method usually 
sacrifices the life of the child. 
PLAGUE. Synonym.-Pest. It is qualified as 
Oriental, Egyptian, Levantine, or Pali plague. 
Mahamari (northwest India) is plague. 
Definition.-An acute specific fever, common to 
man and some of the lower animals, usually at- 
tended with painful swelling of a group of super- 
ficial lymphatic ganglia, cardiac depression, hem- 
orrhages, and a high mortality. In favorable cases 
it runs its course in 9 or 10 days and is followed 
by prolonged convalescence. 
Cause.-Invasion and proliferation of Bacillus 
pestis. This bacillus belongs to that group which, 
Bacillus of Bubonic Plague.-(Yersin.) 
while causing several different diseases, is charac- 
terized by the production of septicaemia hoemor- 
rhagica in all. It is pleomorphic; stains with all the 
simple dyes, but not by Gram's method; in smear- 
preparations some bacilli (only) show bi-polar 
staining. Direct inspection of smear-preparations 
is a valuable aid to diagnosis, but in doubt critical 
differentiation of the suspected microbe is essential, PLAGUE 
PLAGUE 
and can be made only by an experienced bacteri- 
ologist. 
The germ gains entrance through the digestive 
and respiratory tracts, but especially through 
abrasions of the skin. Filth is a potent predispos- 
ing cause. The rat is a medium of transmission 
from house to house, while man in his travels is the 
agent of transmission through long distances. 
Flies, fleas, ants, and other insects may transmit 
the disease, while almost any of the lower animals 
are subject to it. 
Clinical Varieties.-Three forms are distin- 
guished by prominent clinical features: the bubonic. 
the septicemic, and the pneumonic. In milder 
bubonic cases the infection is confined to the 
lymphatic system; when fatal, however, this form 
always becomes septicemic, and the bacillus may 
be demonstrated in the blood-stream during the 24 
hours preceding death. In the pneumonic form 
infection is, perhaps, by the lungs, to which the 
morbid process is usually limited. To these forms 
epithets have been applied, (a) " Black" has been 
used of those cases in which subcutaneous hemor- 
rhages impart that color to the general surface, 
(b) "Fulminant" {pestis siderans') denotes those in 
which death occurs in from 1 or 2 to 24 hours after 
manifestation of the first signs of illness, (c) 
"Ambulant" is applied when the symptoms, 
though well marked, are so moderate that the 
patient is able to attend more or less efficiently 
to his business, or spends but a single day in bed; 
this distinction has value only in relation to the 
widely held opinion that the infection is diffused 
mainly by human intercourse, (d) The term 
"pestis minor" has been applied to two forms of 
illness. One is abortive (or larval) plague, which 
stands on all-fours with abortive smallpox; a 
transient feverishness and headache are attended 
with prickling or actual pain in a superficial 
lymphatic gland, which sometimes becomes swol- 
len, and may even suppurate; reference to pres- 
ence of a declared epidemic at the same time and 
place is necessary to support the diagnosis. The 
other consists in very slight fever, and swelling of 
an inguinal gland which cannot be referred to 
any definite cause; it may be met with "before, 
during, after, or in the absence of, epidemic 
plague" (Cantlie). There is thus no evidence that 
it originates in plague-infection; and as it has been 
described chiefly within the tropics, it has come to 
be called " climatic bubo." 
Incubation.-There is no good evidence that the 
incubation period ever exceeds 5 days; it is very 
often limited to 3 days, or somewhat less. 
Prodromes and Onset.-Prodromal symptoms are 
at most but rarely seen, and are but doubtfully dis- 
tinguishable from the commencement of illness. 
In the great majority of cases the onset is sudden; 
often the patient can name to an hour the time at 
which he was attacked. Rarely it is gradual, and 
extends over 4 or 5 days of increasing illness, after 
which the patient suffers in one of the ways to be 
described below. Such symptoms cannot be 
described as prodromal; their lenity and gradual 
ingravescence are applicable by reference to the 
mode in which infection takes place. 
Symptoms.-First, in every epidemic most cases 
are bubonic. Among colored races the proportion 
may be roughly estimated at 75 percent, the re- 
mainder being of the septicemic form, with a few 
only of the pneumonic; but among whites it is 
larger, cases of the septicemic form being fewer, 
and the pneumonic absent, or but 1 or 2 per- 
cent of the total. Second, the bubonic cases pre- 
sent every shade of severity, from the mildness of 
the ambulant variety upward. An average course 
is described: 
1. The period of onset may be regarded as endur- 
ing about 12 hours; it resembles that of the acute in- 
fectious fevers in general. Feelings of chilliness or 
a rigor (in infants a convulsion), with frontal or 
vertical headache, are accompanied with nausea or 
vomiting, and sometimes by a slight diarrhea, and 
thirst. Discomfort or aching is felt in the limbs, 
and a severer pain in the loins or the lower abdo- 
men. The face is flushed, the skin hot and dry; 
the temperature rises to 38.5° or 39° C. (101.3° to 
102.5° F.); the pulse is full, of normal tension, and 
moderately quickened; respiration is quickened 
apart from lung-affections; the eyes are suffused; 
toward the end of the term there may be restless- 
ness, and signs of mental confusion. Before, at, 
or shortly after an attack stiffness, pricking, or 
lancinating pain may be complained of in the groin, 
armpit, or neck; on palpation, tenderness is dis- 
covered; no tumefaction may be detected, or a 
single gland may be found very slightly enlarged, 
and in size from a pea to half a shelled almond. 
2. A period of ingravescence ensues, during 
which the symptoms are developed in their totality; 
it may be regarded as lasting about 36 hours. The 
face is now pale; the expression apathetic, or dazed, 
or anxious, or terrified; hebetude is succeeded by 
restlessness, delirium with delusions, or mania; 
on being roused the patient collects himself with 
difficulty, and is sometimes angry at being dis- 
turbed; questions are intelligently though briefly 
and tardily answered; speech is frequently but not 
invariably blurred from incoordination of the 
muscles, and should the patient gain his legs, the 
latter is further manifested by staggering. There 
are sleeplessness, anorexia, and thirst; constipa- 
tion is the rule; vomiting is continuous, the rejected 
matters being yellow, greenish, or bluish; except in 
the severest cases the urine is normal in amount, 
acid, sometimes offensive. The temperature rises 
to 41.5° or 42° C. (106.7° to 107.6° F.); the skin re- 
mains hot and dry; the pulse alters in character, 
and becomes rapid, small, easily compressible, and 
even in cases of moderate severity is often dicrotic. 
The tongue is swollen, moist, and characteristically 
furred; the dorsum carries a light creamy coating 
through which red papillae show, while the tip and 
edges are clean and bright red; but during this stage 
it begins to become brown and dry. The gland 
which was first the seat of pain enlarges; other 
glands of the same group become slightly swollen; 
pain or tenderness becomes severer with the in- 
creasing tension, and the patient disposes his limbs 
so as to lessen pressure; swelling of other groups 
may begin, but is attended with much less pain. 
3. From the third to the sixth or seventh day PLAGUE 
PLAGUE 
may be distinguished as the period of state. The 
temperature usually falls to from 38.5° to 39° C. 
(101.3° to 102.5° F.), and thereafter, although 
rising with the occurrence of suppuration in the 
bubo, never attains the height it had previously 
reached. The patient presents an aspect of ex- 
treme prostration; decubitus is dorsal; the face is 
pallid or shallow, and pinched, sometimes singularly 
expressionless from relaxation of the muscles; the 
eyes are closed, or half open; the conjunctiva in- 
jected, especially at the palpebral angles. The 
tongue is dry, brown, and retracted; sordes appear; 
constipation continues, but severe diarrhea with 
tympanites sometimes supervenes and is likely to 
be followed by death; the urine is not diminished 
in quantity, but in about 75 percent of cases con- 
tains albumin in small quantity, hyaline casts, and 
renal epithelial cells, and is often slightly tinged 
with blood. A peculiar odor exhales from the 
body. Delirium gives place to stupor or coma; but 
at beginning of this stage, or in milder cases, rest- 
lessness attended with desire for change of place 
continues; all patients require constant watching, 
and often mild restraint. Cardiac depression be- 
comes marked; the pulse is small, feeble, dicrotic, 
or running and uncountable. External hemor- 
rhages appear: epistaxis, hematemesis, melena, 
hematuria, purpura. The bubo often attains a 
considerable size; it becomes involved in a doughy 
swelling, which mats together and obscures the 
whole group of glands; the skin over the large 
tumor becomes reddened. At any time during this 
stage a slight bronchitis may develop, and in a con- 
siderable proportion of cases scattered patches of 
pneumonia also occur. Death commonly happens 
between the fourth and the seventh days; occasion- 
ally the intellect remains clear to the end; most 
often stupor precedes death. 
4. But if the patient survive, the period of 
decline is ushered in by a fall of temperature to 
normal or a little below it, usually by crisis, 
sometimes by lysis; whereupon the skin becomes 
moist and sleep returns; the pulse continues ex- 
tremely feeble, and the least effort is liable to 
cause death by syncope. The bubo w'hich oc- 
casionally disappears by resolution may usually be 
opened; but sometimes partial resolution is fol- 
lowed by late suppuration about the twelfth day; 
the temperature, which has risen again during sup- 
puration, then falls, and remains normal. 
5. During convalescence cardiac failure, aphasia, 
peripheral neuritis, paraplegia, hemiplegia, or 
facial paralysis may occur; gangrene of the skin 
may set in; interstitial keratitis and panophthal- 
mitis sometimes lead to loss of sight in one or 
both eyes. 
Septicemic Form.-The attack is violent; the 
temperature soon attains to 41° or 42° C. (106.7° 
to 107.6° F.); prostration is extreme from the 
beginning; early delirium rapidly gives place to 
coma; there are no buboes; hemorrhages commonly 
occur; diarrhea and tympanites are frequent. 
Death often happens within 24 hours, and life 
seldom extends beyond the fourth day; two-thirds 
or more of such cases in whites are fatal. 
Pneumonic Plague.-In the preceding forms 
bronchopneumonia frequently occurs; the respira- 
tion is then much quickened; the expectoration is 
abundant, but little aerated, and streaked with 
blood; later it becomes tenacious, devoid of air, 
and rusty or mucopurulent. But this, which is 
due to local arrest and subsequent development 
of the bacillus, is an incident. Primary plague- 
pneumonia consists in a bronchopneumonia which 
is attended by moderate fever, a quickened pulse, 
only slightly quickened respiration, a slight 
cough with watery, serosanguinolent expectoration, 
which is not rusty but blood-stained (prune- 
juice); the characteristic of this form of plague 
being prostration and illness out of all proportion 
to the physical signs. It is almost always fatal, 
and endures about 5 days. 
Postmortem Appearances.-Externally, vibices, 
petechise, or larger ecchymotic patches are com- 
monly present; less often the remains of pustular or 
vesicular eruptions (contents sanious, scabs black), 
carbuncles, infiltrated areas of skin which may be 
sloughing, occasionally great edema of one limb 
from pressure on the great veins at the armpit 
or groin. In the commoner bubonic form a tumor 
of varying size exists at the angle of the jaw, lower 
in the neck, in the axilla, under the outer border of 
the pectoralis major, or in the groin. Internally, 
the blood is liquid, or ill coagulated, the serum 
hemoglobin-stained; normal shades of white and 
yellow are wanting, all the tissues presenting a dirty 
red tinge which strikes the eye. The primary 
external bubo is due to enlargement of one gland 
of the affected set to the size of a bean, or from that 
to a walnut, and of the rest of the group to a 
moderate extent. The former is in a state of 
intense, purple, inflammatory congestion, and is 
softened or broken down at several points; there is 
inflammatory congestion of the surrounding tissues; 
a blood-stained gelatinous effusion, which often 
penetrates even the subjacent muscles, mats the 
whole group into one edematous mass in which 
it is difficult to identify the glandular tissue by 
inspection; the other glands of the group are less 
swollen, and congested. All the lymphatic glands 
of the body are blood-full, rosy to purple on section, 
one member of some group other than that in 
which the primary bubo is seated (more rarely, of 
several groups) may be found rather more enlarged; 
and deeply congested; these latter are secondary 
buboes. In primary plague-pneumonia a bubo 
may be found in the lymphatic glands connected 
with the lungs. In all internal parts submucous 
and subserous hemorrhages are seen, from the size 
of a pin's head to several square inches in area. 
The various visceral changes are: Brain: 
Inflammation of the meninges and meningo- 
encephalitis have been noted. Lungs: Hypostatic 
congestion, almost always; in addition, scattered 
foci of lobular pneumonia, distinguishable from 
other varieties only by the intense inflammatory 
reaction of the surrounding lung tissue; rarely 
a whole lobe is found solidified. Such patches 
result from localization of the bacillus; but oc- 
casionally the pneumonia is primary, and the 
manifestations of the disease are then confined 
to the respiratory system (primary plague-pneu- PLAGUE 
PLAGUE 
monia). Hearf. The pericardial fluid increased in 
quantity, sanguinolent; petechiae of the visceral 
pericardum; myocardium pale and softened. 
Kidneys: There is always acute parenchymatous 
inflammation more or less advanced; hemorrhages 
in the adrenals. Liver: This organ is normal in 
volume; there is degeneration of the parenchyma 
and a nutmeg-section; on the upper surface whitish 
specks and small patches are seen, which indicate 
necrotic areas. Spleen: Enlarged, dark, soft, or 
diffluent; trabeculae obscured; rarely it is normal 
in size and consistence. Stomach and intestines: 
These present petechi® on both surfaces; internally, 
submucous edema, with a slight enlargement of 
the glands. The bacillus may be demonstrated at 
all centers of localization in all hemorrhages, and in 
the general circulation. It must be remembered 
that death not infrequently occurs early, as well 
as suddenly, from cardiac failure, when most of 
the above signs are wanting. 
Diagnosis of the classic form is not difficult; 
during an epidemic a careful observer soon learns 
to recognize the sudden onset, peculiar aspect, 
early muscular prostration, state of tongue, and 
increasing depression of the circulation; which, 
if attended or followed by glandular pain and 
swelling, then often suffice to establish it. Never- 
theless discrimination of plague from streptococcic 
septicemia is often difficult, especially when the 
point of entry is not apparent, or, if found, when 
lymphangitis is absent; and when absolute certainty 
is desirable (at beginning of epidemics, or in cases 
in which exposure to plague-infection is possible 
though not known, as at seaports), bacterioscopy 
can alone furnish the proof. A sterilized metal 
box, containing a tube of sloped nutrient agar, 
and an ordinary hypodermic syringe should be 
furnished from the hygienic laboratory. If the 
case be bubonic, the skin should be carefully 
cleansed with soap followed by alcohol; the swollen 
gland having been steadied and the skin over it 
rendered tense, the hypodermic needle should be 
carefully and steadily thrust into it; the piston is 
then to be slightly withdrawn half a dozen times, 
the needle also being partly withdrawn, and 
thrust into different parts of the gland. In this 
way sufficient liquid can usually be removed. 
The contents should then be carefully projected 
onto the agar surface, and both tube and needle 
(the latter not cleansed) carefully replaced in the 
box and transmitted to the laboratory, where the 
bacteriologist will make smears, cultures, and 
inoculations into animals. In primary pneumonia, 
diagnosis turns entirely on demonstration of the 
bacillus in the sputa, although the remarkable 
disproportion between the auscultation signs and 
the patient's evident danger may have aroused 
suspicion. In septicemic cases the blood may 
be examined; the bacillus is often discoverable in 
this form in the peripheral circulation about 24 
hours after attack (a little earlier or later as the 
case may be). 
Plague may be confused with malarial inter- 
mittent, relapsing, and typhus fevers, and with 
acute alcoholic poisoning. In intermittent fever 
the patient is likely to have dosed himself with 
quinin, when no hemamebae will be found; however, 
the algid stage is much more intense and longer, 
while the hot stage is unattended by great prostra- 
tion, and muscular strength and intelligence are 
preserved. In relapsing fever examination of the 
blood reveals Spirillum Obermeieri; the attack is 
sudden with vomiting, but there is less prostration; 
the face is injected, and expresses neither hebetude 
nor anxiety. During epidemics of plague atten- 
tion is drawn to many cases in which glandular 
swellings are present, but unattended by important 
constitutional symptoms; and in a considerable pro- 
portion it will be found impossible to assign any 
definite cause to them. Some of them may, no 
doubt, be cases of pestis minor at a late stage; but 
there is a belief that this explanation should be 
very cautiously accepted; for attention is then 
arrested by cases which at other times would be 
treated with simple remedies without need appear- 
ing to investigate their exact cause. However, 
the banal causes-venereal or scrofulous disease, 
sepsis, and injury-should in every case be ex- 
cluded as a matter of routine. 
Prognosis.-This should always be very care- 
fully guarded until the eighth day of illness has 
passed; patients are then unlikely to die of the 
fever; but the degenerated heart-muscle exposes 
them to great risk from syncope, which even the 
effort of rising from the supine to the erec.t sitting 
posture in bed may cause. At the commence- 
ment of illness it should be borne in mind that the 
mortality of plague among colored races is always 
between 80 and 90 percent, in whites it is usually 
about 33 percent, while primary plague-pneu- 
monia is almost always fatal, as are about two- 
thirds of all septicemic cases in whites. A sudden 
fall of temperature to below normal, attended with 
coldness and dampness of the surface occurring 
during the period of state, betokens death (the 
internal temperature continues to rise); sharp 
diarrhea with or without tympanites, and external 
hemorrhages, unless in very small amount, are 
both of grave import. The situation of the pri- 
mary bubo is important, a fatal issue more fre- 
quently attending on buboes in the neck than in 
the armpit, least frequently on those in the groin. 
Convalescence is always lengthy. Occasionally 
recovery from the effects of the acute morbid 
process fails, and death by exhaustion occurs many 
weeks later. 
General treatment is symptomatic. Attempts 
may be made to encourage elimination by calomel 
and diuretics; fever may be reduced by cold or 
tepid sponging, although failing circulation may 
render application of heat to the feet necessary at 
the same time, but drugs, unless free from risk of 
depressing the heart, are hardly admissible for this 
purpose. To combat sleeplessness, ice to the head 
is valuable, but morphin, tetronal, trional, hyo- 
scyamin, hyoscin, and the bromids may be em- 
ployed, a combination of morphin and atropin, or of 
morphin and potassium bromid, being specially 
valuable. Against cardiac depression alcoholic 
stimulants, especially champagne, are most useful, 
but to them digitalis and strophanthus given by 
the mouth to strengthen contraction of the cardiac PLAGUE 
PLAGUE 
muscle, with digitalis and strychnin to counteract 
feebleness of the blood-vessels, must be added. It 
is said that the best results have followed sub- 
cutaneous injections of a combination of strophan- 
thus and strychnin; of which latter, as well as of 
some other drugs, plague-patients are remarkably 
tolerant. As to buboes, early incision, leeches, 
and excision are harmful. Extract of belladonna 
may be applied to them, but ice gives most relief 
to pain. As soon as there is clear evidence of pus 
they should be opened by a free incision, such as 
will afford exit to sloughs; and antiseptics should 
be applied to the cavity. Phenol, in doses of 12 
grains every 2 hours, diluted, has been used with 
marked success. 
Specific treatment consists in the administration 
of subcutaneous and intravenous injections of 
Yersin serum; other serums are known, but this 
appears on the whole to have yielded so far the 
best (though still not satisfactory) results. Sub- 
cutaneous injection should be made in that area 
of skin the lymphatics of which converge to the 
primary bubo, and at a moderate distance below 
the latter. The quantity injected at one time may 
be from 40 c.c. to 80 c.c. or more. For intravenous 
injection a vein on the dorsum of the hand, or one 
at the bend of the elbow, should be selected; a 
ligature should be put on the limb so as to bring 
the vein into prominence; this should be further 
rendered tense by pressure of the thumb of the 
hand used to steady the limb, as in venesection; a 
hollow needle can then be plunged into it. Pene- 
tration of the vein is ascertained by beginning to 
inject before the ligature is removed; if it swells, 
the latter may be loosened and the injection com- 
pleted. The quantity injected should not exceed 
40 c.c. at any one time, but in severe cases this 
may (and should) be repeated after 5 or 6 hours. 
Intravenous administration is the more effectual. 
The serum causes a fall of temperature; the clinical 
guide to repetition is a rising temperature. Every 
case should receive a subcutaneous injection of 
40 c.c. as soon as the clinical diagnosis has been 
madfe; but in severer cases 40 c.c. should at once 
be given intravenously, and at the same time 
another 40 c.c. subcutaneously. These massive 
doses, repeated at least twice in 24 hours, give the 
patient a chance of recovery, and seem, on the 
whole, to have sometimes succeeded; and as even 
smaller quantities are followed by reduction of 
temperature and improved arterial tension, the 
remedy, from which no ill effect need be appre- 
hended, should be pushed. A sterilized diphthe- 
ria-antitoxin or other suitable syringe may be em- 
ployed; the operation must be done with every 
asceptic precaution. All serums which have been 
stored present a slight deposit; this may be injected 
with the serum subcutaneously, but should be 
filtered out before introduction into a vein; and it 
need hardly be added that every care to avoid 
introducing air must be used in the latter case. 
Injections are liable to be followed by urticaria 
and joint-pains. 
Specific preventive treatment consists in sub- 
cutaneous administration of 10 c.c. of Yersin 
serum, or of Haffkine's prophylactic in the dose for 
adults which is mentioned on each bottle, and 
which is usually 5 c.c. The former confers a pas- 
sive immunity which is manifested immediately; 
the latter brings about active immunity which 
does not develop for about 8 days. Hence Yersin's 
serum should be used for protection of the mem- 
bers of a household among whom an indigenous 
case has appeared; their danger will cease either on 
removal from the premises or as soon as ordinary 
thorough cleansing and disinfection has been done. 
But Haffkine's prophylactic should be used for 
protection of individuals who are subject to pro- 
longed intermittent exposure, by being obliged to 
visit the infected quarters of a city or to attend on 
the sick. The inoculation should be done at the 
back of the upper arm with aseptic precautions; 
it is not painful. It is followed in a few hours by 
slight malaise and headache, with feverishness; 
the ensuing night is often sleepless; the tempera- 
ture has risen to 38.5° or 39° C. (101.3° to 102.5° 
F.) the next morning; after about 24 hours the 
puncture is found to be the seat of a small hard 
swelling, and there is a good deal of redness and 
diffuse swelling of the superficial tissues below it; 
the slight feverishness and malaise disappear in 
the course of the second 24 hours, having been, 
as a rule, not such as to interfere with usual en- 
gagements, and the redness and superficial swelling 
a little later; the hard swelling persists for about 
3 weeks. Inoculation with prophylactic during 
the incubation-period does not aggravate the 
illness when it commences. Its general effects are 
to lessen liability to attack and to improve chances 
of recovery if attack should occur. 
General Preventive Treatment.-Bacillus pestis 
is the cause of plague; it is found in the bodies of 
the sick, from which it may escape with excretions 
and secretions, with the pus of bubonic abscesses, 
and with discharges from those eruptions and skin- 
lesions which have the same specific origin. In 
the vast majority of cases it enters the body by 
inoculation through the skin; but in primary 
pneumonic cases it probably gains access through 
the respiratory muscous membrane. It can sur- 
vive in viable and even in virulent form outside 
the human body; but this knowledge has been 
drawn from laboratory experiments the results 
of which, as M. J. Rosenauhas judiciously observed, 
must not be applied to the varying conditions of 
daily life without reserves and cautions. As a mat- 
ter of fact, the bacillus has been observed outside the 
human body only in the bodies of animals, among 
which rats and mice have most importance from 
their close association with man, and in the bodies 
of suctorial parasites, among which, again, fleas 
are of most importance. Then, it is now generally 
conceded that, as a matter of fact, the infection is 
very rarely conveyed from the sick suffering from 
the bubonic and septicemic forms to the healthy; 
only the pneumonic form is highly infectious, 
probably (as in tuberculosis) when the healthy 
inhale specks of saliva and expectoration pro- 
jected in coughing. These appear to be the im- 
portant facts touching diffusion of plague as it 
appears among a civilized population of whites, 
and from them the general precautions necessary PLASMODIUM 
PLASTER, ADHESIVE 
in individual cases can be deduced. Importation 
to an average poor household (and multo majore to 
better placed households) of a case which has 
received the infection elsewhere appears to in- 
volve no risk to others even in absence of such 
precautions during the earlier days of illness as are 
usually taken with the commoner infectious fevers. 
It being clearly understood, however, that these 
latter are necessary in prudence, no more need be 
said on the subject of personal prophylaxis; 
nevertheless the central health authority (whose 
operations do not fall within the scope of this 
article) will properly insist on removal of every 
case of plague to hospital at the earliest moment, 
or else, when that is impossible, upon retaining 
the control of the home nursing-staff in his own 
hands. Acid sublimate solution 1: 500 for mixing 
with excreta, etc., and the same 1:1000, together 
with 5 percent carbolic solutions for other pur- 
poses are as useful disinfectants as any. Proper 
sanitation should be established; the dead should 
be cremated, and all infected articles burned if 
possible. Rigid quarantine of persons, animals, and 
goods, should be enforced. Infection has not in- 
frequently been conveyed by rats and cargoes; con- 
sequently the cargo of every suspicious ship should 
be fumigated and all rats aboard as well as on shore 
should be destroyed. The direct agent in convey- 
ing the infection from rats to man being the rat- 
flea, disinfection of clothing and kit of travelers 
should be insisted upon. 
PLASMODIUM.-See Malarial Fevers. 
PLASTER (Emplastrum).-An adhesive, solid 
or semisolid, medicinal substance spread upon 
cloth or other flexible material, for application to 
the external part of the body. Plasters are usu- 
ally spread on muslin, leather, paper, etc., and have 
as a basis, lead plaster, a gum-resin, or Burgundy 
pitch. P., Antiseptic, a plaster consisting of the 
ordinary adhesive plaster dipped in a hot solution 
of carbolic acid (1 :60). P., Black, lead plaster. 
P., Casts, a model of an object produced by 
pouring plaster-of-Paris mixed with water into a 
mold of that object. P., Court-, a plaster prepared 
by dissolving 30 grams of isinglass in enough water 
to make 360 grams, and spreading the mixture 
thinly upon silk in two portions, one the watery 
solution, the other mixed with 120 grams of alcohol 
and 3 of glycerin. The reserve side of the silk is 
painted with tincture of benzoin. It adheres 
firmly to the skin when moistened. P., Diachylon. 
Synonym of P., Lead. P., English. Synonym of 
P., Court-. P., Isinglass, a substitute for adhesive 
plaster, used in superficial wounds. P., Jacket, 
a bandage surrounding the trunk, and made of 
plaster-of-Paris. It is used in caries of the verte- 
brae. P., Logan's, a plaster containing litharge, 
lead carbonate, Castile soap, butter, olive oil, and 
mastic. P.-machine, an apparatus used by phar- 
macists for spreading plasters. P., Mahy's, one 
containing lead carbonate, oilve oil, yellow wax, 
lead plaster, and Florentine orris. P., Miraculous, 
one containing red oxid of lead, olive oil, alum, and 
camphor. P., Mull, a plaster made by incorpo- 
rating mull or thin muslin with a mixture of gutta- 
percha and some medicament dissolved in benzin. 
P., Mustard, one made by spreading powered mus- 
tard, or a mixture of mustard with flour or other 
powder, reduced to the consistency of paste by the 
addition of water, upon muslin. P., Pitch, a plas- 
ter containing Burgundy pitch, frankincense, 
resin, yellow wax, oil of nutmeg, and olive oil. P., 
Rademacher's, a plaster composed of red lead, 
olive oil, amber, camphor, and alum. P., Resin, 
a plaster composed of resin, lead plaster, and yel- 
low wax or hard soap. See Plaster (Adhesive). 
P., Rubber, a plaster in which the adhesive mate- 
rial is spread on thin muslin, and which sticks with- 
out being previously warmed. P., Spice, a plaster 
composed of yellow wax, suet, turpentine, oil of 
nutmeg, olibanum, benzoin, oil of peppermint, and 
oil of cloves. P., Sticking-, emplastrum resinae. 
P., Stomach. See P., Spice. P., Strengthening, 
emplastrum ferri. P., Surgeon's, adhesive plaster. 
P., Thapsia, one containing yellow wax, Burgundy 
pitch, resin, terebinthina cocta, Venice turpentine, 
glycerin, and thapsia resin. P., Vesicating, can- 
tharides plaster. P., Vigo, one containing lead 
plaster, yellow wax, resin, olibanum, ammoniac, 
bdellium, myrrh, saffron, mercury, turpentine, 
liquid storax, and oil of lavender. P., Warm, P., 
Warming, emplastrum picis cum cantharide. 
There are seven official plasters: 
Title. 
Constituents. 
Emplastrum : 
Adhsesivum 
Rubber, 20 gm.; petrolatum, 
20 gm.; lead plaster, 960 gm. 
Extract of belladonna leaves, 
300 gm.; adhesive plaster, 700 
gm. 
Adhesive plaster. 
Belladonnas. (Should not 
contain less than 0.38 
percent, nor more than 
0.42 percent of mydriatic 
alkaloids.) Belladonna 
plaster. 
Capsici 
Oleoresin of capsicum, 0.25 
gm.; adhesive plaster, q. s. 
Mercury, 30 gm.; oleate of 
mercury, 1 gm.; hydrous 
wool-fat, 10 gm.; lead plaster, 
59 gm. 
Extract of opium, 6 gm.; water, 
8 c.c.; adhesive plaster, 90 gm. 
Soap, 100 gm.; lead acetate, 60 
gm.; water, sufficient quantity. 
Soap, 10 gm.; lead plaster, 90 
gm.; water, sufficient quantity. 
Capsicum plaster. 
Hydrargyri 
Mercurial plaster. 
Opii 
Opium plaster. 
Plumbi (Diachylon plaster.) 
Lead plaster. 
Saponis 
Soap plaster. 
PLASTER, ADHESIVE.-The lead adhesive 
plaster was universally used before the introduction 
of the rubber adhesive plaster, and which, because 
it is less irritating to sensitive skins, is still preferred 
by some practitioners. It is made by adding to 80 
parts of lead plaster 14 parts of resin and 6 parts 
of yellow wax. It is then spread on muslin pre- 
pared for the purpose. Adhesive plaster, while 
based upon the lead plaster, is rarely, if ever, used 
for the purposes of exhibiting the impression of 
oxid of lead. 
To obtain the best results from adhesive plaster, 
the material must be freshly cut from a roll which 
has been kept in a tin box or other close-fitting 
receptacle. The plaster is best heated over an 
alcohol lamp or against the side of a vessel con- PLASTER-OF-PARIS 
PLASTIC SURGERY 
taining hot water (the smooth or nonadhesive side 
being placed in contact with the heated surface 
until the plaster is thoroughly softened), when it 
must be immediately applied to the skin. Placing 
a strip of adhesive plaster around a stove-pipe, 
with the adhesive side out, will often prove prac- 
ticable in private practice. When strips are used, 
which, from their great length it is inconvenient 
to heat, the plaster surface may be softened by 
rubbing it over with a bit of raw cotton moistened 
with chloroform or ether. 
Adhesive plaster may be worn for weeks at a time 
without producing cutaneous irritation. Hence it 
is to be preferred to rubber plaster for making 
extension for fracture of the thigh, or for affections 
of the hip-joint. Firmly applied over an ulcer and 
supported by a bandage, it forms a reliable 
method of dealing with leg ulcers due to varicose 
veins. Adhesive plaster is extensively employe^ in 
the treatment of fractured ribs and contusions of 
the chest. A number of strips about 2 inches wide 
are applied parallel to the ribs, beginning at the 
lowest and passing up to the axilla. Each strip 
is to be applied with firm traction, and extend 
from the vertebral column to a point a little be- 
yond the median line in front. Marked relief is 
afforded by this procedure. In fracture of the 
clavicle in children a dressing of adhesive plaster 
will be found a satisfatory means of keeping the 
ends of the bone in position. Sayre's dressing for 
fractured clavicle is made of adhesive plaster. 
Sprains are often strapped with adhesive plaster. 
PLASTER-OF-PARIS.-Gypsum or calcium sul- 
phate is used for making stiff or immovable band- 
ages and dressings, and for the preparation of 
casts. An ordinary creolin or loose-web bandage 
is well rubbed with fine plaster-of-Paris. The 
bandage is then applied to the part wet, additional 
plaster is rubbed in, and the cast thus formed 
is allowed to dry or "set." 
The method of testing the quality of plaster-of- 
Paris is by taking a small pinch of the powder be- 
tween the thumb and finger and gently rubbing it; 
if small particles of grit are felt, it indicates that 
parts of the plaster have already absorbed water, 
and it is therefore unfit for use. The same test 
may be observed by taking a pinch of the powder 
again and placing the fingers under water, and 
then rubbing in the same way as before. If, 
however, in both of these tests no grit is felt, 
and, under water, a thin, creamy substance 
is formed which is easily rubbed off the fingers, 
the plaster is in a proper condition for use. 
When plaster has been kept for a long time, 
or when it is gritty, its condition can be very 
greatly improved. It may be redried by putting 
it in a metal dish, such as a pie-plate or 
iron pot, and placing it in an oven of a hot 
stove or over a gas-jet. As soon as it becomes 
heated, it will be observed that a process identical 
with boiling water is taking place. When this 
ebullition has entirely ceased, the powder is freshly 
kiln-dried. If the method of testing is again 
resorted to, it will be found that the gritty ap- 
pearance and feeling will have disappeared in a 
very large measure, leaving only the now dry 
powder ready for use. If there are any lumps 
remaining, they may be removed by the use of a 
sieve. Plaster-of-Paris must always be kept in a 
hermetically sealed jar, or in a very dry place. 
To Remove a Plaster Dressing.-In order to 
facilitate the removal of plaster-of-Paris dressing 
from limbs, the following plan should be followed: 
After application of the usual thin layer of absor- 
bent cotton around the limb, parchment paper, 
which has been previously moistened, is wet and 
applied. Over this, in the direction that the 
dressing is to be sawed open, a good sized string 
which has been well rubbed with vaselin is laid 
on and the dressing then applied. The ends of the 
string are then tied together over the bandage. 
When in the course of time the plaster dressing is 
to be laid off, the ends of the cord are untied, one 
tied to the end of a sufficiently long steel wire, 
which has been closely nicked, is drawn through 
the channel filled by the oiled string, and after 
each end of the wire has been attached to the 
handles of a chain saw, it is drawn to and fro until 
the plaster has been sawed through. Then the 
dressing is easily removed. 
PLASTIC SURGERY.-Plastic surgery is that 
branch of the operative art by which congenital 
or acquired defects and deformities are repaired. 
With the extension of surgery, plastic operations 
have been extended from the skin, to which they 
were long limited, to the various mucosae, to 
bone, to tendon, and to nerve. The present article 
will be limited to its considerations as applied to 
the skin alone. 
The rationale of all plastic surgery is based on the 
inherent vitality of tissues after they have been re- 
moved from their original site and implanted in 
a new position, whence they thereafter obtain 
nutrition. In dermatoplastic operations two 
chief methods are to be considered: 
Gliding Pedicle, or Flap.-Those procedures in 
which the skin to be utilized for filling a gap re- 
tains, for a time at least, some connection with its 
original site. 
Skin-grafting Proper.-In this method of plastic 
surgery the integument utilized may be taken from 
the body of the patient himself. For this the term 
autoplasty is used. Heteroplasty is reserved for 
the utilization of tissues from a person other than 
the patient, or from an animal. 
For the relief of many defects-as, for example, 
of the lip, the eyelid, or a part of the nose-the 
first method is still the only one applicable. The 
area of the defect is first to be freshened by 
clean incisions extending through the entire 
thickness of the skin. All scar tissues must be 
removed. By doing this the defect will be seem- 
ingly greatly increased. The margins and floor 
of the wound should be made as smooth as possible, 
and all bleeding checked before proceeding to 
shape the skin structures which are to cover the 
gap. In fashioning the skin to be transferred, one 
of two plans may be followed: (1) That of gliding, 
and (2) that of making a flap to be nourished by a 
pedicle. 
The gliding method of closing a defect by traction 
on the vivified edges of the skin surrounding it, is PLASTIC SURGERY 
PLASTIC SURGERY 
based on the extent to which skin can be stretched 
and yet retain its vitality. Oval or triangular 
defects, or such as can be converted into either 
shape, are best suited for a gliding operation. To 
facilitate the gliding of the skin destined to cover 
the gap it is undermined for a varying distance. 
This is a safe method; it leaves no new defect 
and the broad attachment of the skin assures its 
viability even under considerable tension from 
traction. When the form and size of a defect 
preclude its closure by traction alone, the skin in 
the immediate vicinity may be dissected up in a 
patch of requisite size and by a process of gliding 
be brought edgewise into the position of the part 
to be repaired, when, after proper adjustment, 
it is retained by sutures. Triangular or rectangular 
defects, such as follow partial removal of the lip 
or of the eyelid, can best be repaired in this way. 
When the gliding method is impracticable, 
flap formation must be resorted to. The defect is 
vivified, as in the gliding operation. The flap 
is taken from the most available part. Usually 
it is taken from near the defect. It may, however, 
be taken from a distance, as in rhinoplastic opera- 
tions, where the skin flap is taken from the arm. 
To cover large defects of the extremities, as after 
burns of the elbow or wrist, the integument may be 
taken from the abdomen or side of the chest. Mr. 
Croft's operation, in which this is done, is of 
greatest value in the conditions named. In this 
procedure a flap of skin 6 or 8 inches long, and 
2 or 3 inches wide, is raised from the underlying 
tissues of the abdomen and retained by bridges 
of skin above and below. For a week or 10 days 
the under surface is allowed to granulate. Now 
only is the lower attachment of the flap severed and 
brought into the freshened gap-as, for example, 
of the elbow or wrist-and sutured there. Until 
firm union has resulted, the arm is firmly bandaged 
to the side of the body. After another 10 days, 
the upper bridge is severed, and the flap finally 
placed in its new position. 
Viability of the flap is the first requisite of suc- 
cess. It should be fashioned to insure a sufficient 
blood supply. It should contain the entire 
thickness of the skin and a part of the underlying 
subcutaneous layer. Bleeding flaps are viable. 
From the natural contractility of the skin, flaps 
shrink considerably. They should, therefore, 
be cut one-third larger than the defect to be filled. 
In formal plastic operations the pedicle should 
measure not less than 1 inch in width. Excessive 
torsion of the pedicle must, for obvious reasons, 
be avoided. The fixation of the flap by sutures 
forms the final step of the plastic operation. Ac- 
curacy of apposition is essential. The absence of 
blood within the wound and strict aseptic and 
antiseptic precautions tend to assure success. In 
plastic operations about the face the buried sub- 
cuticular suture is particularly to be advocated. 
The after-treatment is simple. A dry gauze 
dressing, held in position by bandage or strips 
of adhesive plaster, will go far toward supporting 
the parts and assuring primary union. 
Skin-grafting.-In 1869 Reverdin first published 
a method of rapidly causing the closure of super- 
ficial wounds and ulcerated surfaces by implanting 
in them small grafts of epidermis that had been 
entirely removed from the body. The grafts were 
the size of a pin's head, and deposited in little 
depressions made with a knife in the surface to be 
covered. From these grafts the epidermis devel- 
oped in minute islands, which, as they grew, 
coalesced, and eventually covered the entire sur- 
face. The method of Reverdin was often uncer- 
tain and slow in achieving a result. For this rea- 
son it failed of general adoption, and was entirely 
superseded by that of Thiersch, advanced in 1886. 
This is based on the viability of strips of the super- 
ficial layers of the skin when entirely removed 
from their original sources of nutrition, and their 
tendency to form permanent attachment to de- 
nuded surfaces. Wolfe, in 1868, and after him a 
number of ophthalmic surgeons, transplanted large 
portions of the skin from the arm in plastic opera- 
tions on the eyelids. 
Among the conditions in which skin-grafting by 
large films is indicated may be mentioned: (1) 
Indolent ulcers, as of the leg, or those following 
burns. (2) Fleshy denuded areas resulting from 
the removal of neoplasm, as after the excision of 
superficial epitheliomata or lupus patches from the 
face. Immediate closure of the wound can thereby 
be accomplished. (3) After excision of extensive 
growths, as for mammary cancer, when the wound 
cannot be closed by traction suture without dan- 
gerous tension. (4) Areas of the bone that have 
recently lost their covering of soft parts, and can 
be covered in no other way. Areas of bone ex- 
posed after necrotomy operations. Skin-grafts 
unite readily to aseptic bone surfaces. 
Operation.-The locality where the skin is to be 
grafted must be a flesh wound, or, in the case of an 
ulcer, it must be so converted by removing all 
granulations by the use of the sharp spoon. All 
hemorrhage must be checked by hot salt solutions 
and compression. The presence of blood under the 
graft would, more than all else, endanger the suc- 
cess of the procedure. Unevenness in the floor of 
the defect does not militate against the adherence 
of the grafts. 
The epidermal strips are usually taken from the 
anterior surface of the thigh or from the outer sur- 
face of the arm. This part should be sterilized, as 
for ordinary operations, some time before the 
strips are cut. When everything is ready for 
cutting the strips, the skin is made tense by the 
left hand of the operator or by an assistant. A 
constant flow of salt solution likewise is directed 
against the field of operation. With a sharp, 
broad razor, preferably plane on one surface, the 
surgeon cuts strips of the epidermis and papillary 
layer of the skin. The cutting is done parallel to 
the surface, and by a to-and-fro or sawing move- 
ment. The strips are cut of requisite length and 
width, and may be made an inch or more wide, 
and 5 or 6 inches long. Each strip is at once trans- 
ferred to its new habitat and placed in position 
with raw surfaces in opposition. The edges of the 
graft have a marked tendency to curl in a manner 
that would bring the epidermis underneath. This 
can easily be corrected by gently using a probe and PLETHORA 
PLEURISY 
mouse-tooth forceps. As many strips as may be 
needed are cut and placed in position. The edges 
should be made to slightly overlap. When there 
has been no bleeding under the grafts, adhesion 
takes place rapidly, probably as a result of atmos- 
pheric pressure. 
Dressings after skin-grafting should be aseptic, 
not antiseptic. Solutions of corrosive sublimate 
are harmful. The dressing may be that of rubber 
protective or silver-foil or oiled silk moistened with 
salt solution. An excellent dressing is gutta- 
percha tissue in that it can be readily sterilized by 
formaldehyd fumes, is pliable and free from odor, 
and is not disintegrated by body temperature and 
moisture. The gutta-percha tissue cut in narrow 
strips is applied directly to the newly grafted sur- 
face. Over this the ordinary gauze and cotton 
dressing are retained by a bandage. The gauze 
dressing is removed daily and sterile normal saline 
solution is applied with a camel's-hair brush to 
clear away any exudate that appears between the 
strips. 
In exceptional cases the entire thickness of the 
skin is utilized for the graft (Wolfe's method). A 
flap of the desired size and form is outlined by an 
incision to the fascia. The edge of the skin is 
raised with mouse-tooth forceps, and the flap re- 
moved from the subcutaneous layer by long and 
even strokes of the knife. Fat lobules are to be 
carefully removed from the flap before it is placed 
in its new position. 
As a rule, the skin is very pale and continues so 
for a number of days after transplantation. 
Sutures are, as a rule, unnecessary, if not harmful. 
The after-treatment is the same as for the epider- 
mal graft. With many operators, gold-beaters' 
skin or silver foil is made to take the place of the 
moist rubber protective dressing. 
PLETHORA.-Abnormal fulness of blood or 
superabundance of blood. Serous plethora is an 
excess of serum in the blood. The best drug for 
affections of plethoric subjects is aconite, and it is 
decidedly the best remedy for apoplexy in the 
plethoric. When there is a determination of blood 
to the head, arsenic may be used to advantage, 
while sulphur is to be used as a mild purgative for 
plethora from cessation of the menses. For 
abdominal plethora, saline and hydragog cathar- 
tics are of service. The purgative saline waters, 
such as Vichy or Saratoga, are also valuable. 
Grape-juice has helped many cases. Dry diet is 
indicated in dyspepsia and hepatic enlargement 
from excessive beer-drinking. Avoid much bread, 
salted or twice-cooked meats, rich sauces, solid 
vegetables, especially soups, cucumbers, and fruits. 
Biscuits, fresh meats, lemons, fish, fowl, and game 
may be used. 
Venesection (q. v.) is sometimes employed. 
1$. Resin of podophyllin, gr. vj 
• Compound extract of colo- 
cynth, gr. xij 
Alcoholic extract of bella- 
donna leaves, gr. iij. 
Divide into 12 pills. Give 1 pill every 
night. 
PLEURA, INJURIES.-Rupture of the costal 
pleura probably occurs spontaneously in every 
case of fractured rib or severe contusion of the 
thorax, but, owing to the skin being unbroken, the 
injury is repaired at once, with only a transient or 
local pleurisy at the most; and though such com- 
plications as hematothorax from rupture of an 
intercostal or internal mammary artery and 
pneumatocele may occur, they are very rare. 
When there is an external wound, the pleura only 
may be injured, without the lung, if the weapon is 
^plunt and enters the thorax slowly, so that it 
pushes the lung in front of it, or if the wound is in 
the tenth or eleventh interspace; for though the 
pleura usually extends as low as the last rib, the 
lung, unless it is emphysematous, only reaches the 
tenth. In this case, however, the diaphragm and 
the subjacent viscera are very likely to suffer. 
Other complications depend upon the size and 
extent of the wound. If it is merely a puncture 
or a small incision, the diagnosis is often never 
made; but if it is extensive, the lung may protrude 
without injury through the opening (hernia)', it 
may collapse and fall back, leaving the pleura full 
of air (pneumothorax); the cavity, as already 
mentioned, may be partly filled with blood, and 
the air may either pass in and out freely through 
the wound (traumatopnea), or it may be forced into 
the cellular tissue under the skin, and spead over a 
considerable area (emphysema). This, however, 
is seldom extensive unless the lung is wounded. 
Finally, at a later period, pleurisy may set in, and 
even run on to empyema. See Chest (Injuries), 
Lung (Injuries), Pleurisy. 
PLEURISY.-Inflammation of the pleura. 
Varieties.-According to cause, it may be divided 
into primary or secondary; according to extent, 
into unilateral, bilateral, or local; according to 
time, into acute or chronic; and according to the ex- 
udation, into serofibrinous, fibrinous, or purulent. 
Etiology.-(1) It may be idiopathic from expo- 
sure to the cold and wet; (2) traumatism; (3) it is 
usually associated with lobar pneumonia and peri- 
carditis; (4) it is secondary to certain infective and 
toxemic conditions, such as acute rheumatism, 
pyemia, typhoid fever, gout, nephritis, and tuber- 
culosis (common); (5) cancerous (rare). 
The exciting cause is said to be infection by pneu- 
mococci, staphylococci, or streptococci. 
Pathology.-Pleurisy consists of three stages: 
(1) Stage of congestion; (2) stage of effusion; (3) 
stage of organization or absorption. In the early 
stage, to the naked eye the pleura is red, swollen, 
and covered with flakes or curds of yellowish or 
whitish lymph (dry pleurisy). The process may 
stop in this stage, or the effusion may accumulate 
in large quantities in the pleural sac (serofibrinous). 
It may be only covered with a film of deposit 
mostly fibrinous (fibrinous), or it may become 
infected, giving rise to purulent pleurisy 
(empyema). 
Serofibrinous Pleurisy.-The amount of fluid 
varies greatly from half an ounce to several pints. 
As the liquid accumulates in the stage of effusion, 
it gravitates toward the lower portion of the pleural 
sac, compressing the lung upward and backward. PLEURISY 
PLEURISY 
The diaphragm is displaced downward and the 
heart toward the opposite side of the lung affected. 
The fluid may be absorbed, may be organized into 
new tissue, or may become purulent. 
Fibrinous Pleurisy.-In this form the deposit is 
scanty, thick, whitish or yellowish in color, and 
generally circumscribed. A considerable amount 
The cough is distressing, generally being cut short 
by the sharp pain in the side. The sputum is occa- 
sionally tinged with blood; in certain cases the spu- 
tum may be profuse, while in others it may be 
suppressed. As the disease progresses, dyspnea 
becomes apparent, and the patient lies on the 
affected side to relieve the intense pain set up dur- 
ing the course of the disease. As the fluid accumu- 
lates, this symptom gradually abates, the fever 
becomes lower, while the respirations still remain 
embarrassed. 
Physical Signs. Stage of Congestion.-There 
are diminished expansion and, perhaps, decreased 
tactile fremitus over the affected area. On aus- 
cultation a to-and-fro grazing, creaking, or crack- 
ling friction sound is heard. The crackling sound 
is often mistaken for crepitant or subcrepitant 
rales. If due to rales, the sound is generally 
removed by coughing, while in the former in- 
stance the sound is not modified. 
Stage of Effusion.-There is diminished expan- 
sion over affected area, often bulging of intercostal 
spaces and displacement of apex-beat to the 
right or left, according to pleura affected. Palpa- 
tion confirms inspection; diminished vocal (tactile) 
fremitus.' Percussion elicits movable dulness. 
If the upper level is at the third intercostal space 
when the patient is in sitting posture, it will be at 
fourth interspace or lower when lying down. The 
line of dulness is usually curved, being higher pos- 
teriorly. Above the line of dulness a zone is 
found which yields a hyperresonant (tympanitic) 
note, or Skoda's resonance. On auscultation the 
respiratory murmur is weak, the expiratory 
breath-sound frequently being inaudible in the 
stage of effusion. Earlier in the disease bronchial 
breathing is present, most marked along the spine 
and interscapular region. A friction sound may 
be detected above the level of the fluid anteriorly 
in some cases. Vocal resonance is diminished in 
the stage of effusion, but when bronchial breathing 
is present in cases of moderate effusion, broncho- 
phony may be heard. The unaffected lung is 
doing vicarious work, and both inspiration and 
expiration are harsh in quality on that side which 
also yields a hyperresonant note. When there is a 
small amount of fluid present, egophony is elicited, 
most marked near the angle of scapula of the 
affected side. Mensuration shows increase in 
anteroposterior diameter on affected side. Aspira- 
tion detects the presence and character of fluid, 
whether serofibrinous or purulent. The white 
blood-corpuscles, red cells, and hemoglobin 
remain about normal. 
The Stage of Absorption.-There is gradual 
return to the normal physical signs. Occasionally 
friction redux is detected. 
Physical Signs of Chronic Fibrinous Pleurisy.- 
Chronic pleurisy may result from the acute form, 
the fluid not being absorbed, and therefore yields 
the same physical signs as in acute form. In dry 
or plastic pleurisy (chronic) on inspection the 
chest is greatly deformed on affected side. Palpa- 
tion yields diminished vocal (tactile) fremitus. 
On percussion there is impaired resonance. Aus- 
cultation detects pleuritic grazing or creaking 
Cells from Exudate, Case of Empyema.-(.Coplin). 
The large hyaline cells (macrophagocytes) contain many 
pneumococci. 
of cellular infiltration may occur, giving rise to the 
formation of new tissue and causing the two sur- 
faces of the pleura to be bound together (adhesive 
pleurisy). If the process is a progressive one, the 
lymphatics may become involved, spreading to the 
lung and causing bronchopneumonia. 
Purulent pleurisy (empyema) generally results 
by metastasis during the course of pneumonia or 
tuberculosis. An empyema, however, may be 
primary or may become purulent by infection dur- 
ing the course of a serofibrinous pleurisy. The 
septic process may cause erosion of the visceral 
layer, thus extending to the lung and finally the 
bronchi, when the purulent collection may be dis- 
charged during the act of coughing. If the rup- 
ture takes place in the parietal layer, the pus 
burrows its way externally, producing an abscess 
in one or more of the intercostal spaces, generally 
near the sternum. In young patients this process 
generally causes great deformity of the chest after 
the pus has been evacuated. See Colon Bacillus 
Infection. 
Hemorrhagic Pleurisy.-Effusion of blood in 
the pleural sac, resulting from cancer, tuberculo- 
sis, scurvy, and grave forms of anemia. 
Symptoms and Clinical Course. Acute Pleurisy. 
-The onset is generally marked by chilly sensa- 
tions, slight cough, the act of which gives rise to a 
sharp pain (stitch) in the affected side. The tem- 
perature is somewhat elevated (100° to 102° F.), 
pulse full and only moderately increased in rate, 
and frequently not corresponding to the height of 
fever. The respirations are increased, often being 
painful, especially on taking deep inspirations. PLEURISY 
friction sounds, and diminished vocal resonance. 
The respiratory murmur is diminished in intensity. 
Symptoms of Purulent Pleurisy (Empyema).- 
There are hectic symptoms, sweats, chills, high 
irregular fever, dyspnea, expectoration of very 
offensive material, edema and redness in the in- 
tercostal spaces, and on aspiration the purulent 
fluid is obtained. 
Diagnosis depends upon the subjective and ob- 
jective symptoms. 
light diet, such as sweet milk, soup, beef-juice, 
soft-boiled eggs, rice, bread and butter. The chest 
maybe enveloped in flannel or a light cotton jacket. 
Pain is relieved by hypodermic injections of 
morphin (1/4 grain) with atropin (1/125 grain), 
and by strapping chest with adhesive plaster. If 
the pulse is strong and bounding, the tincture of 
veratrum viride (20 minims) or the tincture of aco- 
nite (10 minims) may be given every 3 hours until 
5 or 6 doses have been taken. Late in the disease, 
when the effusion is great, these drugs are danger- 
ous on account of the profound depression in- 
duced by their action. In the early stages blisters 
add to the distress of the patient; late in the 
disease a series of small blisters do good. As 
in ascites, catharsis may have some influence 
in diminishing the amount of fluid in the pleural 
cavity. Of the different remedies, possibly mag- 
nesium sulphate (4 drams) is the best. It should 
be given before breakfast. Compound jalap 
powder (20 to 40 grains) every 4 hours may 
be taken instead of the salts. Three bowel move- 
ments a day are sufficient. If the fluid shows no 
signs of absorption before the second or third 
week of the onset of disease, one of two methods 
remains to be chosen: First, to get rid of the 
effusion by means of blisters and cathartics; sec- 
ond, to aspirate. Each method has its advocates. 
Removal of Effusion by Blisters and Cathar- 
tics.-As has been mentioned, possibly magne- 
sium sulphate (4 drams), preferably taken before 
breakfast, is the most reliable drug. At the time of 
administration of the purgative it is best to restrict 
the amount of water and liquid food to the mini- 
mum. A series of small blisters (1/2 by 2 inches) 
may be induced by cantharidal plaster over the 
affected region; when signs of healing are noticed, 
a new site may be selected for the blisters. The 
daily application of the tincture of iodin may be 
substituted for the blisters. The administration of 
potassium iodid (6 grains 3 times a day) is also 
recommended. 
Removal of the Fluid by Aspiration.-Aspiration 
is always indicated in the following conditions: 
(1) When the level of fluid extends above the 
third rib; (2) when the dyspnea is intense; (3) 
when it remains unabsorbed from 2 to 3 weeks of 
onset, or after subsidence of the fever; (4) when the 
disease is bilateral and the total amount of fluid 
present is equal to the volume of one pleural sac; 
(5) when the fluid is purulent (empyema). Resec- 
tion offers the most hope to the patient in the last 
instance. 
The patient should take the sitting posture. 
The point for introduction of aspirating needle is 
either at the outer angle of scapula in eighth in- 
terspace, or near the posterior axillary line in the 
seventh interspace. Either point may first be ren- 
dered as aseptic as possible, and after anesthetizing 
the part by means of a few drops of a solution of 
cocain (5 percent), the needle is introduced with a 
quick thrust into the pleural sac and the cannula 
withdrawn. If the fluid does not at once drain 
away, it may be due to the needle being plugged 
with fibrin-inserted too far or not far enough. 
It is not a good plan to rotate the needle in different 
PLEURISY 
Acute Pleurisy. 
Lobar Pneumonia. 
Intercostal 
Neuralgia. 
Subjective Symptoms. 
Subjective Symp- 
toms. 
Subjective 
Symptoms. 
1. Onset marked by 
1. Onset marked by 
1. Onset mark- 
chilly sensations, 
shaking chill, 
ed by stitch in 
sharp cough. 
cough, dyspnea. 
side, pain 
along inter- 
costal spaces. 
2. Cough often check- 
2. Cough gives rise 
2. Cough ab- 
ed by darting pain 
in side. 
to pain in throat 
and general chest 
pains. 
sent 
Objective Symptoms. 
Objective Symptoms. 
Objective Symp- 
toms. 
1. Fever slight (100°) 
and very irregular. 
1. High fever (104°) 
with diurnal varia- 
tion. 
1. Fever absent. 
2. Slight dyspnea (20 
2. Dyspnea great 
2. Respiration 
to 30 respirations 
(40 to 50 respira- 
normal. Pa- 
a minute). Patient 
tions a minute). 
tient lies on 
lies on affected side. 
Patient uncom- 
fortable in all 
positions. 
affected side. 
3. Inspection. - Di- 
3. Physical signs 
3. Dimini shed 
minished expansion 
observed in pleu- 
expansion dur- 
of affected area and 
bulging of inter- 
spaces ; heart dis- 
placed. 
risy are different. 
ing inspiration. 
4. Palpation. - Di- 
4. Increased vocal 
4. Normal vocal 
m i n i s h e d tactile 
(vocal) fremitus. 
fremitus. 
fremitus. 
5. Percussion.-Per- 
5. Percussion-n o t e 
5. Pere u s si o n- 
cussion-note dull 
over effusion, 
movable dulness, 
Skoda's resonance 
from effusion. 
dull. 
note normal. 
6. Auscultation.- 
6. Bronchial breath- 
6. Respiratory 
Respiratory mur- 
ing, crepitant rale 
murmur nor- 
mur diminished, 
egophony at angle 
of scapula, grazing 
or crackling pleuri- 
tic friction sound. 
on inspiration, in- 
creased vocal re- 
sonance (broncho- 
phony). 
mal. 
7. Mensuration.-Af- 
7. Diameter both 
7. Diameter of 
fected side increas- 
ed in diameter. 
sides of chest 
equal. 
chest equal. 
8. Sputum may con- 
8. Sputum contains 
8. Sputum nor- 
tain streaks of blood 
(uncommon). 
blood ("rusty col- 
ored") and diplo- 
cocci. 
mal. 
9. Aspiration detects 
9. No fluid with- 
9. No fluid on 
fluid. 
drawn on aspira- 
tion, as a rule. 
aspiration. 
Prognosis.-For acute pleurisy in adults the 
prognosis is favorable. In children great deform- 
ity of chest may ensue. In purulent pleurisy the 
prognosis should be guardedly favorable if the 
fluid is removed early. In tubercular pleurisy the 
prognosis is unfavorable. 
Treatment demands absolute rest in bed and a PLUMBUM 
directions for fear of lacerating the parts. If the 
quantity of fluid is excessive, about two-thirds 
should be drawn off, and the remainder allowed 
to remain for 2 or 3 days. During the latter 
part of the process the patient frequently feels 
faint, and a small quantity of whisky should be 
at hand to combat the exhaustion. 
Thoracoplasty, or Estlander's operation, consists 
in removing a portion of several of the ribs, for the 
purpose of allowing the chest-walls to fall in, in 
cases of empyema where, after the pleura has been 
drained, the lung, in consequence of adhesions, 
does not expand. An incision 3 or 4 inches in 
length may be made obliquely downward and in- 
ward over the side of the chest, just in front of the 
latissimus dorsi, across the ribs the portions of 
which it is intended to excise. The edges of the 
wound being retracted to expose the ribs, an in- 
cision is next made through the periosteum along 
the course of each rib for the required distance, 
the periosteum separated with a raspatory from 
both the outer and inner surface, and the rib then 
cut through with the saw or bone-forceps at each 
end of the incision, the soft parts being protected 
by a spatula passed beneath the rib. 
Autoserotherapy.-The withdrawal of a syringe- 
ful of the exudate and hypodermic injection of it 
immediately is apparently efficacious, especially in 
acute cases. Repeated injections may be neces- 
sary in severe cases. 
Vaccine and open-air treatment has recently 
been used with success, the vaccine administered 
being autogenous. 
PLUMBUM.-See Lead. 
PNEUMATIC CABINET.-See Pneumother- 
apy, under Tuberculosis, Pulmonary; Lungs 
(Surgery). 
PNEUMOGASTRIC NERVE, DISEASES.-Anat- 
omy.-The pneumogastric nerve arises from the 
oblongata, between the origins of the glosso- 
pharyngeal and spinal accessory nerves. It passes 
through the jugular foramen, and is joined by 
branches of the spinal accessory. Giving off small 
branches, it passes down the neck behind and in 
the same sheath with the carotid artery, enters the 
thorax on the right side over the subclavian artery, 
and on the left between the subclavian and the 
carotid arteries. It passes through the thorax, 
beside the esophagus, and ends in branches to the 
stomach, spleen, and intestines. The most im- 
portant branches are the pharyngeal, the superior 
laryngeal, the recurrent laryngeal, which passes 
back-the left around the arch of the aorta, the 
right around the subclavian artery. Branches pass 
to the esophagus and pulmonary branches to the 
lung and to the cardiac plexus for the heart. The 
nerve may be affected at its nucleus of origin, in 
its trunk, or in the terminal branches. 
Etiology.-The nucleus most frequently is af- 
fected with bulbar paralysis, while tumors or aneu- 
rysms compress it within the skull, or it may be in- 
volved in meningeal thickening, whether syphilitic 
or otherwise. In the neck it may be compressed 
by aneurysm or glandular tumors, and is most 
liable, especially in the recurrent branch, to be 
ligated or wounded. When wounded it is neces- 
PNEUMONIA, CROUPOUS 
sary to remember that its fibers are composed of 
accelerator and depressor motor fibers for respira- 
tion, depressor fibers for the heart, motor and 
sensory fibers for the esophagus, and some sensory 
and motor fibers for the stomach. 
Symptoms.-When the pharyngeal branches are 
affected, there is difficulty in swallowing, as they 
supply the constrictors of the pharynx and the 
levator palati muscle. When the laryngeal 
branches are affected, the voice usually becomes 
hoarse; coughing is impossible, and the glottis can- 
not be closed. Paralysis of the muscles of one side 
of the larynx is a prominent symptom when the 
trunk of the vagus in the neck or the recurrent 
is affected. In locomotor ataxia bilateral paraly- 
sis occurs, when the spinal accessory nuclei are 
affected-as is also the case in diphtheria and in 
bulbar paralysis. Bilateral spasm is often pro- 
duced reflexly. In epilepsy the cry is produced by 
a tonic contraction of the vocal cords, and is part 
of the cortical discharge occurring locally. The 
"laryngeal crises" of locomotor ataxia are due 
to local irritation of the spinal accessory nucleus. 
Spasm of the pharynx is paroxysmal in charac- 
ter, and is almost always part of functional ner- 
vous diseases. It forms part of the spasm of 
hydrophobia, and occurs in hysteria. In emo- 
tional states, as in fear and intense grief, swallow- 
ing may be impossible from such spasm. 
Spasm of the laryngeal muscles is manifested 
in the adductors. When the recurrent branch is 
affected, direct spasm usually affects only one vocal 
cord. 
Treatment.-The general treatment of diseases 
of the pneumogastric nerve depends upon the 
different causal conditions. Central disease is, 
as a rule, beyond the range of treatment. Potas- 
sium iodid will often remove suspected causes of 
pressure. In laryngeal paralysis electricity, local- 
ly applied, is often of benefit. Strychnin injec- 
tions are also sometimes useful. In spasmodic 
affections, sedative* inhalations, especially of 
chloroform, are useful, and applications of cocain 
will diminish afferent impressions of the larynx. 
Bromids and morphin lessen the irritability of 
the nerve-centers. 
PNEUMONIA, CATARRHAL.-See Broncho- 
pneumonia. 
PNEUMONIA, CROUPOUS (Lobar Pneumonia; 
Fibrinous Pneumonia; Acute Pneumonia; Pneu- 
monitis). 
Definition.-Pneumonia is an acute specific 
disease, due to infection with the diplococcus 
pneumonias (pneumococcus of Fraenkel) and, 
rarely, with other microorganisms, characterized 
by a fibrinous exudation into the pulmonary 
air-cells and bronchioles, and following a course 
that is more or less typical, the chief symptoms 
being those of toxemia and of interference with 
the respiratory and circulatory functions. Strep- 
tococcus-pneumonia is regarded as a more or 
less distinct form of pneumonia. 
Etiology.-The greatest predisposition to pneu- 
miona is in early adult life; it is less common as a pri- 
mary disease before 20 and after 50 years. Women 
are nearly four times more liable to it than men, PNEUMONIA, CROUPOUS 
PNEUMONIA, CROUPOUS 
and it is more prevalent among the negroes in 
America than among the whites. There are 
more cases in the winter and early spring, and 
fewest from June to December, and it is relatively 
more rife in the Southern than in the New England 
States. Surgical operations, ether narcosis, and 
previous attacks are also predisposing causes. 
As a secondary disease it is associated with 
epidemic influenza, typhus and enteric fever, 
variola and other exanthems, diphtheria, erysipe- 
las, puerperal septicemia, acute dysentery, whoop- 
ing-cough, tuberculosis, acute and chronic neph- 
ritis, diabetes, malaria, gout, and chronic alcohol- 
ism. Emphysema, asthma, and chronic valvular 
heart-disease are said to confer a certain immunity. 
Bacteriology.-It is now believed that the essen- 
tial cause of pneumonia is a microorganism, and 
that the disease is a specific one. Although pro- 
longed exposure to cold and sudden chilling are 
followed by attacks, yet if the accepted theory of 
pneumonia is true, such incidents prepare the tis- 
sue of the bronchioles and alveoli for infection, but 
do not in themselves cause the disease. The 
same may be said of contusions, fracture of the 
ribs, and other traumatic causes which are some- 
times followed by pneumonia. The diplococcus 
of pneumonia is found in health in the mouth and 
upper air-passages, but infection does not take 
place unless some other influences, such as those 
mentioned, are brought into play. The micro- 
have been found, as Pfeiffer's influenza bacillus, the 
streptococcus pyogenes, the staphylococcus aureus, 
and the typhoid bacillus. In view of these facts 
and of the failure of Fraenkel's parasite to produce 
pneumonia in animals by inoculation, it cannot 
be asserted that there is one specific cause of pneu- 
monia. (See, too, Colon Bacillus Infection.) 
Sputum, Croupous Pneumonia.-(Coplin.) 
In the extreme upper part of field is a leukocyte showing 
chromatolysis but containing englobulated cocci. Below 
and slightly to the left of this cell is a squamous cell from 
the mouth. To the right of the latter and slightly below 
is a polymorphonuclear leukocyte, and in the extreme lower 
part of the field is a small hyaline cell. The field also con- 
tains numerous encapsulated pneumococci a few streptococci 
and unarranged cocci that cannot be identified with accuracy. 
Pathologic Anatomy.-The general distribution 
of lesions in pneumonia proves that it is a general 
disease. The lung presents the most serious 
changes, but the blood, serous membranes, kid- 
neys, and spleen show decided alterations. 
Lungs.-It is usually stated that the lower lobe 
of the right lung is involved in three-fourths, and 
alone affected in one-half, of all the cases. Pye- 
Smith's figures give a different conclusion from 
this. Out of his 434 cases, the right base was the 
seat of disease in 140, the left base in 151, the right 
apex in 60, and the left apex in 20 cases. There 
were 8 cases of central and 55 of double pneumo- 
nia. Apical pneumonia is much less common than 
pneumonia of the base. Double pneumonia occurs 
in about one-sixth of the cases; it may involve both 
bases, or the apex of one and the base of the other 
lung. The inflammation spreads upward from 
the base and downward from the apex, and the 
tendency of the disease is to implicate the whole 
lobe or the entire lung. 
The changes through which the lung passes are 
conveniently divided into three stages: (1) 
Congestion or engorgement; (2) consolidation or 
hepatization; (3) resolution. 
1. Stage of Congestion and Serous Exudation.- 
The affected lung in this stage is congested, more 
resistant to touch, has somewhat increased weight 
and density, and is darker in color. On section 
a bloody liquid exudes, the tissue is brighter red 
than normal, and there is less crepitation on pres- 
sure. Toward the end of this stage the color is 
darker red, the density is greater, and there is even 
less crepitation, but pieces of the affected part 
Pneumococcus of Fraenkel in Sputum of Pneumonia, 
Gram's Stain and Eosin.-(.Williams.) 
organisms usually gain access to the alveoli 
through the bronchial tubes, but they may reach 
the lung through the circulation; this is shown by 
the presence of the pneumococcus in the exudate of 
meningitis, pericarditis, endocarditis, and in other 
lesions complicating fibrinous pneumonia, and by 
its occasional discovery in the blood. 
The specific microorganism most frequently 
found in typical fibrinous pneumonia is the diplo- 
coccus pneumonise (the pneumococcus of Fraenkel). 
There are cases presenting the characteristic symp- 
toms and physical signs in which other bacteria PNEUMONIA, CROUPOUS 
still float in water. From the resemblance of the 
lung to splenic tissue, this condition is called 
splenification. The increased density and changed 
color are found, microscopically, to be due to 
overdistention of the blood-vessels of the alveolar 
septa, and to the exudation of serum with the 
escape of leukocytes and a few red blood-cells into 
the alveoli and bronchioles. 
2. Stage of Fibrinous Exudation and Solidi- 
fication (Hepatization).-In this stage, beginning 
on the second or third day, the lung is increased in 
bulk and 3 or 4 times in weight; it is inelastic and 
liver-like in density and appearance (red hepatiza- 
tion). The cut surface is dark red or brownish- 
red, dry, and granular; crepitation is absent, and 
pieces sink in water. The tissue is friable and 
breaks down under rough handling. 
The corresponding pleura, both parietal and 
costal, is covered with a layer of thick, soft lymph. 
At this period the alveoli and smallest bronchi are 
completely filled with a fibrinous exudate, seen 
with the microscope as a network of thread-like 
lines, with entangled leukocytes, red blood-cells, 
exfoliated alveolar epithelium, and diplococci or 
other microorganisms. It is this exudate which is 
the essential and characteristic feature of fibrinous 
pneumonia; by filling and then coagulating within 
the alveoli and minute bronchi, it renders the 
lung airless and solid. Later in this stage, the 
exudate compresses the alveolar capillaries and 
makes the tissue bloodless. Thus, "gray hepati- 
zation" is brought about, the lung remaining solid, 
but the color changing to grayish or yellowish- 
gray. Thrombi fill up the branches of the pul- 
monary artery as far back as the large vessels, 
but the nutritive vessels are pervious. 
3. Resolution.-Between the fifth and eighth 
days, usually, the exudate begins to soften, and the 
entangled cells, among which are many leukocytes, 
undergo fatty degeneration. Liquefaction is 
followed by absorption, and, when the latter is 
completed, the alveoli are open and the lung is 
restored to a normal condition. In this process the 
lung becomes gradually softer, less resistant, 
and finally elastic. The whole of the affected 
lobe is not going through these stages at the same 
time: while the first part attacked is becoming 
consolidated, neighboring areas are in the state 
of congestion. The sudden crisis of the third 
stage, however, puts an immediate end to all pro- 
cesses. The nonpneumonic portions of the lung 
and the opposite lung may be congested and ede- 
matous; the bronchi are congested or in a catar- 
rhal state, and the bronchial lymph-glands are 
congested, soft, and swollen. 
In drunkards and cachectic individuals the exu- 
date is hemorrhagic, and does not solidify, so that 
the stage of complete consolidation is not reached. 
In cases that have been prolonged, pressure on a 
cut surface leaves a pit that fills up with a purulent 
fluid; this condition, supposed to be a perverted 
and delayed resolution, has been called "purulent 
infiltration." In the terminal stage resolution 
sometimes does not occur, and by the breaking 
down of the septa an abscess cavity is formed; 
this empties into a bronchus, or is encapsulated. 
Gangrene of the lung is a very rare termination, 
as is also a fibrous alteration called fibrous pneu- 
monia or carnification. An abundant serous 
effusion may take place into the pleura (pleuro- 
pneumonia), and not infrequently, especially after 
influenza pneumonia, empyema is a final stage. 
Next in importance to pulmonary lesions are 
those of the heart, for it is upon the relative in- 
tegrity of this organ that the fate of the patient 
most frequently depends. The right heart, as a 
rule, contains red or white clots that extend into 
the branches of the pulmonary artery; the left 
cavities may be empty. The heart-muscles may 
undergo parenchymatous degeneration. Peri- 
carditis, especially in left-sided pneumonia, and 
endocarditis are not unusual. This last has the 
malignant form, and is rapidly fatal. In both 
lesions, as well as in all exudates, the pneumococcus 
has been found. 
In the kidney the cells of the tubules show cloudy 
swelling or granular degeneration, and in a few 
cases there is acute nephritis. 
The liver is congested, and the spleen large and 
soft. 
The nervous system shows few changes, menin- 
gitis being the most common. 
Symptoms.-Primary fibrinous pneumonia is 
always a serious disease, and has a necessary 
intensity, conforming more or less in uncompli- 
cated cases to a definite type. Every variation 
from this type is unfavorable, whether in the 
direction of greater or less intensity, or in the loss 
of essential characteristics. A prodromal period 
of 2 or 3 days is noted sometimes, with nasal or 
pharyngeal catarrh, epistaxis, or loss of appetite 
and diarrhea. 
First Stage.-The onset is sudden, with a chill, 
lasting a half-hour or longer; it is most common 
and most severe in young adults, but is absent in 
the aged and in children. After the chill the pa- 
tient has flushed cheeks, a hot and dry skin, and a 
rapidly rising temperature; he complains of a 
sharp stitch in the region of the nipple, in the 
midaxillary line, or just anterior to the angle of 
the scapula; inspiration increases the pain, and an 
involuntary effort is made to relieve it by making 
the respirations shallow and irregular. A short 
and sharp cough is accompanied by a viscid sputum 
in small masses without air-bubbles, and of a 
peculiar, yellowish-red or "rusty" color. It 
consists of mucus, blood discs, leukocytes, and 
minute casts of the bronchioles. In stained pre- 
parations the diplococci or other microorganisms 
are seen. 
Some importance as a symptom is to be given 
to a group of herpetic vesicles on the upper or 
lower lip, chin, or cheek. The tongue is coated; 
the urine is scanty, high colored and acid, de- 
positing lithates on cooling, with more lessening of 
urea, chlorids, phosphates, and sulphates than in 
other febrile disorders. Headache, a sense of 
illness and prostration, insomnia, and slight 
delirium may be present from the beginning. 
Early in the attack the number of leukocytes in 
the blood is increased from the normal 8000 or 
10,000 to 20,000 and 30,000, or even to 60,000. 
PNEUMONIA, CROUPOUS PNEUMONIA, CROUPOUS 
PNEUMONIA, CROUPOUS 
They grow in number up to the crisis, and then 
quickly drop to the normal proportion. These 
are the symptoms of the stage of congestion and 
last about 2 days. 
The physical signs during this period are di- 
minished expansion, with normal vocal fremitus; 
the percussion-note is less clear, passing into dul- 
ness as consolidation begins; the respiratory 
murmur is feeble or suppressed; moist or dry rales 
may be found, and later there is bronchovesic- 
ular breathing. Crepitation, the only pathogno- 
monic physical sign, may or may not be heard on 
inspiration. A pleural friction sound is rarely 
present. 
Second Stage.-No well-defined line separates 
the symptoms of the second stage from those of 
the first, but by the second or third day an aggra- 
vation of all the symptoms has developed. The 
patient wears a more anxious expression, one or 
both cheeks have a dark, sometimes livid red color, 
the nostrils expand with inspiration, and the lips 
are often dark red, and in some cases purple. The 
temperature at the close of the first or second day 
reaches 104° F. to 105° F., and remains at about 
this maximum with diurnal variations. The 
pulse is 110 to 120, its tension and fulness lessening 
with the progress of the disease and growing feeble 
and intermittent. 
The cough is less frequent than at first, and may, 
by the third or fourth day, cease altogether. The 
same is true of the sputum as well as of the local 
pain; both disappear when the lung is consolidated. 
The dyspnea, on the contrary, increases; the res- 
pirations are shallow, and are 30 to 40 or more to 
the minute, being relatively more frequent than 
the pulse. The tongue has a thick white fur, and 
there is constipation. In some cases jaundice 
occurs. 
The nervous symptoms are very variable, but 
are often the most striking clinical features. 
Headache and general aching may disappear with 
the onset of delirium, which is maniacal or of the 
low muttering character; the active form occurs in 
drunkards and in cases of apical pneumonia; the 
typhoidal form may be present from the beginning 
or toward the end of the first week, and is accom- 
panied by tremor of the limbs and tongue. In 
some instances there is mild delirium at night only, 
the mind being clear during the day, but at all 
times there is an absence of natural sleep. 
The intense toxemia, in addition to the asphyxia 
and disturbance of the heart and circulation, bring 
about a very rapid change in the patient's appear- 
ance. The flushed cheeks, dilating nostrils, rapid 
breathing, and restless movements indicate the 
serious nature of the illness, and the changes for the 
worse, from day to day, are very decided. 
The physical signs of the second stage are: The 
affected side expands less, and vocal fremitus, 
unless there is pleural effusion, is exaggerated. 
There is percussion dulness, with increased resist- 
ance over the solid lung, whether base or apex, 
and this extends upward or downward. Bronchial 
breathing and bronchophony are heard first over 
the locality of beginning consolidation, whence 
they spread over the whole of the pneumonic area. 
Third Stage.-The beginning of resolution is a 
true crisis, and is shown in the sudden drop of the 
temperature and in the change in all the symptoms. 
It comes between the fifth and ninth day, being 
sometimes preceded by pseudocrisis; a normal or 
subnormal point is reached in from 5 to 15 hours, 
and is followed by a natural sleep, free sweating, 
and relief from suffering. The patient then enters 
upon convalescence. 
On physical examination a subcrepitant rale 
(rale redux) is heard in the midst of the bronchial 
breathing, and the signs of consolidation gradually 
disappear with multiplying moist rales. Percus- 
sion dulness may last for some time, owing to the 
pleuritic exudate. By the twelfth or fourteenth 
day the lung has returned to its normal state. 
Death may occur in 36 or 48 hours, or it may 
come in the last days of the first or beginning of 
the second week. Muscular and nervous exhaus- 
tion, with increasing feebleness of the pulse, deli- 
rium and coma, burning dry heat of the skin, cold 
extremities, and cyanosis are symptoms preceding 
death. It may be due to intense infection affect- 
ing the nerve-centers and the heart, to hyper- 
pyrexia, or asphyxia due to loss of respiratory 
surface, or to some complication. 
Variations.-Temporary hyperpyrexia during 
the first 4 days is not uncommon; in about one- 
fourth of the cases a temperature of 105° F. or over 
is maintained for 2 or 3 days, and in fatal cases this 
may be continued to the end. In children vomit- 
ing or a convulsion takes the place of a chill; 
nervous symptoms predominate, and the physical 
signs are slow in developing. As a rule, there are 
no localized pain, cough, or expectoration. In 
the aged the onset is insidious, the fever is less, 
cough and sputum may be absent, and the physical 
signs appear slowly. In alcoholics cerebral symp- 
toms and fever may be the only indications to be 
relied on, the physical signs alone giving sure evi- 
dence of the disease. In the cachexias or in enfee- 
bled constitutions consolidation of the lung is not 
complete; there is great prostration, with prune- 
juice expectoration. 
Instead of resolution occurring on or about the 
ninth day, the progress may be delayed by the 
continuance of fever of irregular course and by 
persisting moist rales. It is under these circum- 
stances that the lung is believed to be in the con- 
dition of "purulent infiltration." Delayed resolu- 
tion and the continuance of the physical signs of 
consolidation with fever may end after some weeks 
in the sudden discharge from the lungs, through 
the bronchial tube, of a large quantity of pus-the 
so-called abscess of the lung. A much graver 
termination is gangrene of the lung, which is 
brought about by the closure of a nutrient vessel 
supplying the pneumonic area; this condition is 
shown by fetor of the breath, an offensive thin 
sputum, great prostration, and sometimes by the 
physical signs of a cavity. 
The symptoms differ more or less from this 
description when pneumonia develops during the 
progress of, or at the end of, the various acute or 
chronic diseases enumerated under the head of 
etiology. It is then frequently the closing event, PNEUMONIA, CROUPOUS 
PNEUMONIA, CROUPOUS 
and the picture is modified by the peculiar symp- 
toms in each case. The anatomic condition of 
the lung and the physical signs are the same, 
however, as in the primary form. In secondary 
pneumonia the chill is usually absent and the 
temperature range is less constant, and, in many 
cases, not so high as in primary pneumonia. 
Cough, sputum, and localized pain may also be 
absent. The breathing is always much embar- 
rassed and the serious nature of the illness is shown 
in the rapid decline of strength. 
Complications.-In the respiratory organs the 
complications of pneumonia are laryngitis, general 
bronchitis, collateral hyperemia, and edema of the 
opposite lung. The fibrinous pleurisy that is a 
necessary part of pneumonia may be attended by 
the effusion of serum (pleuropneumonia) and 
empyema in from 1 to 5 percent of all cases, and 
may develop after the pneumonic symptoms have 
subsided. Pericarditis has been noted in 2 to 
8 percent of cases, and endocarditis was present in 
16 out of Osler's 100 cases, but in only 7 of Pye- 
Smith's 425 cases. The daily examination of heart 
would probably disclose a large proportion of 
cardiac lesions. Symptoms in pericarditis have 
not the same value as physical signs; endocarditis 
has, however, the characteristic and rapidly pro- 
gressive asthenia of the malignant form. Menin- 
gitis occurs in intense general infection, and is 
associated not infrequently with malignant endo- 
carditis; the symptoms are cerebral-active 
delirium passing into the low muttering form with 
coma. Other and rarer complications are acute 
nephritis, catarrhal, membranous, or ulcerative 
colitis, icterus, arthritis, otitis media, parotitis, 
thrombosis of the femoral vein, and peripheral 
neuritis. 
Diagnosis.-Pneumonia developing in a pre- 
viously healthy adult is recognized by the sudden 
chill, the high temperature, side pain, rusty or 
bloody sputum, and by physical signs that point to 
the lung as the seat of attack. Stained specimens 
of the sputum reveal the diplococcus in most cases. 
The subsequent course of fever, with the consolida- 
tion of the lung, the nervous and other symptoms, 
make a picture that is not easily mistaken. If any 
doubt exists, the critical change, at a more or less 
fixed date, clears up all uncertainty. Blood ex- 
amination is of great value, as a leukocytosis of 
from 20,000 to 30,000, and ranging as high as 
60,000, is invariably found; it varies with the 
seriousness of the attack, and continues up to the 
crisis. In secondary pneumonia the features are 
so modified by the primary disease that the diag- 
nosis is often difficult. Physical signs have the 
most value, and the daily examination of the tho- 
rax will often explain the nature of symptoms that 
bear but little likeness to those of pneumonia. In 
drunkards, children, and old persons, fever alone, 
or associated with cerebral disturbance, may 
be the only symptom of a pneumonia that 
would escape detection if the lungs were not 
examined. 
Pleurisy is distinguished from pneumonia by the 
lessened movement of the chest, the absence of 
fremitus, and by egophony. The symptoms, too, 
are less acute, and the characteristic sputum is 
wanting. If pleurisy with effusion complicates 
pneumonia, a judicious interpretation of the united 
symptoms and physical signs makes the diagnosis 
not a difficult one. In cases of great uncertainty 
an aspirator can be used without any danger. 
Bronchopneumonia or catarrhal pneumonia is 
more common than fibrinous pneumonia in in- 
fancy and in advanced life, and as a sequence to 
pertussis and measles. It is preceded by the 
symptoms and physical signs of bronchial catarrh, 
the consolidation is in both lungs, although not 
always at the same time; the sputum is mucopuru- 
lent, and contains no pneumococci, but strepto- 
cocci and staphylococci; the temperature is lower 
and more irregular than in lobar pneumonia, and 
the symptoms are without any definite duration, 
lasting longer, as a rule, than in fibrinous pneu- 
monia and coming to an end gradually without 
crisis. 
In hypostatic congestion with edema, cough, 
frothy, bloody expectoration, and dyspnea are 
present, but there is no chill and little or no fever. 
Slight dulness on percussion and subcrepitant 
rales are found on both sides. 
Apical pneumonia and tuberculosis are some- 
times confounded; both have local pain, cough, 
bloody expectoration, and fever; the physical signs 
of consolidation are the same, although advancing 
at a different rate and running a different course. 
But the fever in pneumonia is continued, and in 
tuberculosis is remittent or intermittent; bacilli in 
the sputum, and the absence of leukocytosis also 
favor the existence of tuberculosis. After 2 weeks 
have passed there can no longer be any question 
if the local signs and the symptoms continue un- 
changed. Cancer of the lung, a rare condition, 
resembles pneumonia up to a certain point, but the 
onset is gradual, without chill or much fever, and 
there are constant pain and rapid emaciation. 
In appendicitis pain and rigidity may be reflected 
through the lower intercostal nerves and simulate 
lobar pneumonia. 
Croupous ; 
Pneumonia. 
Pleurisy. 
Typhoid 
Fever. 
Acute 
Phthisis. 
Subjective 
Subjective 
Subjective 
Subjective 
Symptoms. 
Symptoms. 
Symptoms. 
Symptoms. 
1. Onset sud- 
1. Onset sud- 
1. Gradual on- 
1. Onset sud- 
den, with 
den, with 
set, with 
den, with 
severe 
chill or chilly 
vague pains, 
severe chill; 
chill. 
sensations. 
epistaxis , 
diarrhea, and 
eruption. 
history of 
phthisis in 
family. 
2. Pain in af- 
2. Sharp pain 
2. Pain on pres- 
2. Same as 
fected side 
(stitch) in af- 
sure in right 
pneumonia. 
not so great 
as in pleu- 
risy. 
fected side. 
iliac region; 
tenderness 
about spleen. 
3. Cough 
which in- 
creases 
pain in af- 
fected side. 
3. Severe cough 
often cut 
short b y 
"stitch" i n 
side. 
3. Slight cough. 
3. Same as 
pneumonia. 
4. Delirium 
4. Delirium 
4. D eliri um 
4. Same as 
after first 
two days. 
uncommon. 
frequent. 
pneumonia. 
- 
- PNEUMONIA, CROUPOUS 
PNEUMONIA, CROUPOUS 
Croupous 
Pneumonia. 
Pleurisy. 
Typhoid 
Fever. 
Acute 
Phthisis. 
Objective 
Objective 
Objective 
Objective 
Symptoms. 
Symptoms. 
Symptoms. 
Symptoms. 
1. High fever 
1. Moderate 
1. Moderate 
1. High irre- 
104°, and 
irregular 
fever and 
gular fever, 
very regu- 
lar. 
fever. 
regular. 
frequ e n 11 y 
varying 
several de- 
grees. 
2. Pulse full, 
2. Pulse full; 
2. Pulse di- 
2. Pulse rap- 
bound i ng; 
rate slightly 
erotic; rate 
id and fee- 
rate moder- 
ately in- 
creased. 
increased. 
gradually in- 
creased. 
ble. 
3. Inspec- 
3. Same as 
3. Expansion 
3. Same as 
tion.-Di- 
minished 
expansion. 
pneumonia. 
normal. 
pneumonia. 
4. Palpation. 
4. Diminished 
4. Fremitus 
4. Same as 
-Increas- 
ed vocal 
(tactile) 
fremitus. 
vocal fremi- 
tus. 
normal. 
pneumonia. 
5. Percus- 
5. Percussion- 
5 Percussion- 
5. First stage 
sion.- 
Note i n 
first stage 
hyperreso- 
nant; sub- 
sequent 
dulness at 
base of 
lung. 
note dull. 
note normal. 
same as 
pneumonia; 
later dul- 
ness at apex 
of lung. 
6. Ausculta- 
6. Respiratory 
6. Sonorous 
6. Bronchial 
tion.- 
murmur al- 
and sibilant 
breathing; 
Bronchial 
most inaud- 
rales are 
m u c o u s 
breathing; 
ible; pectoril- 
common. 
small rales; 
crepitant 
rale; bron- 
chophony, 
occasional- 
ly pector- 
iloquy. 
oquy. 
later gurg- 
ling rales. 
7. Mensura- 
7. Increase in 
7 Normal 
7. Normal or 
tion.-Nor- 
anteroposte- 
d e c r e ased 
m a 1 on 
each side. 
rior diameter 
on affected 
side. 
diameter. 
8. Sputum 
8. Sputum 
8. Sputum 
8. S p u t um 
"rusty col- 
whitish, fre- 
normal. 
often con- 
or," con- 
q u e n t 1 y 
tains blood 
taining dip- 
streaked 
and tuber- 
lococci. 
with blood. 
cle bacilli. 
so than double pneumonia, which has a death-rate 
of 50 percent and upward. 
Unfavorable symptoms are a temperature above 
105° F., increasing frequency and weakness of the 
pulse, feeble heart-sounds, prune-juice sputum, 
early delirium of the maniacal or the low muttering 
form, muscular tremor, profuse sweating (except at 
the crisis), excessive tympanites and hiccup, cold 
extremities, and cyanosis and abundant bronchial 
and tracheal rales. 
A slight leukocytosis, below 14,000, or a very 
high leukocytosis with a low temperature, are 
discouraging indications. Complications of the 
heart, kidneys, and meninges of the brain add 
greatly to the danger. 
Secondary pneumonia has no fixed death-rate, 
the result depending upon the nature of the pre- 
vious or coexisting illness; but in all cases the mor- 
tality is higher than when pneumonia begins in 
previously healthy persons. 
Treatment.-Experiments on animals and the 
inoculation of cases of pneumonia with the blood- 
serum of immunized rabbits and of convalescents 
from pneumonia have given much hope that 
ultimately an antipneumotoxin may be found. 
An abortive or distinctly curative treatment can- 
not be employed generally until a successful anti- 
toxin is as readily obtainable as the antitoxin of 
diphtheria. In the meantime pneumonia must be 
recognized and treated as an acute, infective dis- 
ease, tending to self-limitation, the chief dangers 
of which are, first, toxemia, with the resulting high 
fever and exhaustion of the heart and nervous 
system; and, secondly, the lessened air-space and 
obstruction to circulation through the right heart 
and pulmonary vessels. 
Fresh air is of vast importance. The patient 
should be placed in a well-ventilated room, with 
an open fire and open window; the temperature 
of the room should be kept below 70° F.-65° F. 
being the minimum. In no disease is a trained 
nurse more needed, and strict sick-room discipline 
should be maintained from the beginning. The 
strength should be husbanded by the use of the 
bed-pan, and by not permitting the patient to sit 
up for food or for examinations of the chest. 
Milk is the best food-3 to 4 ounces every 3 hours, 
so as to amount to 2 or 3 pints in the 24 hours. 
Tympanites and undigested casein in the stools 
call for a less quantity and for dilution of the milk 
with barley or Vichy water. If there is a distaste 
for milk, koumiss, matzoon, or farinaceous gruels 
may be given as substitutes. The disease is of 
short duration, and but little food can be digested 
and assimilated; fever, prostration, and dyspnea 
will be increased by excessive feeding. The crav- 
ing for liquids must be gratified by the free use of 
cold water, or by any of the effervescent waters. 
The eliminative treatment is important. Per- 
spiration should be promoted and a purgative 
may be prescribed at the start-calomel is the 
best, followed by a saline. No other drug, as a 
rule, is needed in the first stage, and in many cases 
none will be called for throughout the entire ill- 
ness. A. H. Smith believes in the efficacy of 
"an attack upon the pneumococcus through the 
Prognosis.-The fatality of primary fibrinous 
pneumonia varies from 15 to 25 percent. Among 
young, healthy men composing armies, it is much 
less; in 40,000 cases in the German army the death- 
rate was 3.6 percent. In children under 5 years it 
is not above 3.3 percent; after 50 years it reaches 
50 percent and upward. This difference is due to 
the lessened resistance of the aged, and especially 
to senile degenerations in the heart, kidneys, and 
other organs. In hospitals the mortality is higher 
than in private practice, in the proportion of 26.1 
(Osler) to 12 percent. Previous conditions of ill 
health and the drinking habit are the chief causes 
of this difference; the latter has a most fatal in- 
fluence in pneumonia. More deaths occur in the 
autumn and winter than in the spring and summer. 
In individual cases the danger lies in the toxemia 
and in the mechanic interference with respiration 
and circulation. Pneumonia of one lobe is much 
less serious than of the whole lung, and this is less PNEUMONIA, CROUPOUS 
PNEUMONOKONIOSIS 
medium of the blood, the object being that the 
exudate, when it escapes into the air-cell, shall 
be impregnated with a substance that will unfit 
it to serve as a culture medium." To effect this 
may be given calomel, 20 to 30 grains in one dose; 
chloroform or creosote (creosotal preferably) by 
the mouth or by inhalation; quinin, or a salicylate. 
Creosotal is given in 10 minim doses in capsule or 
emulsion every 4 hours. Sodium salicylate or 
aspirin is to be preferred, 60 to 120 grains in 24 
hours, after the plan of Robert Liegel. 
It is claimed for the external applications of 
cold water that, as in typhoid fever, they not only 
reduce temperature, but eliminate the toxins, and 
thus strengthen the heart and relieve the nervous 
symptoms. For adults this can best be done by 
applying to the front and back of the entire chest 
a compress made after the pattern of the oil-silk 
jacket, wrung out of water at 60° to 70° F., and 
covered with flannel. This is reapplied every 
half-hour or hour, according to the height of the 
temperature and the effect produced; it should be 
discontinued when 99.5° F. has been reached. 
Mays uses large, flat, rubber ice-bags-2 to the 
head and 2 or more to the chest. He claims a 
mortality of 4.25 in 400' collected cases treated 
with ice applications. It must be taken into 
account, however, that a number of these cases 
were in children. 
The cold tub-bath is objectionable, because it 
fatigues and excites the patient. Tepid or warm 
baths are preferable. In some cases the warm or 
cold wet-pack, with an ice-bag to the head, has a 
most happy effect, especially in the onset of pneu- 
monia in children, with cerebral excitement and 
high temperature. The patient may be left in the 
pack from one-half an hour to an hour. Cold 
sponging may take the place of the compress or 
pack if a less decided effect is desired. 
In serious cases hypodermoclysis is efficacious, 
1/2 to 1 pint of normal hot salt solution (0.6 per- 
cent) being injected daily or oftener. 
Insomnia is inevitable, and a too vigorous 
effort should not be made to relieve it. It is best 
treated by hydrotherapy, but if there is no sleep 
in 24 hours, alcohol, sodium bromid, chloralamid 
(10 to 20 grains), or hyoscin hydrobromid (1/100 
grain) hypodermically, may be given at night. 
Morphin, however, is most to be relied on for this 
purpose, given hypodermically in doses of 1/32 to 
1/16 grain, and repeated in 1 to 2 hours, the dose 
to be increased on subsequent nights if found to be 
too small. In cases of feeble heart it can be com- 
bined with strychnin or other cardiac stimulants. 
Dover's powder has no advantage over morphin. 
The treatment of delirium is covered by the fore- 
going suggestions. In alcoholic cases it is neces- 
sary to give stimulants according to the degree of 
habitual use. 
The heart and pulse must be sustained from the 
beginning. Alcohol and strychnin, 1/60 to 1/20 
grain, repeated every 3 to 6 hours, are the best 
remedies for this purpose. Atropin, caffein, 
strong coffee, or strophanthus may be used as aids 
or substitutes. Nitroglycerin has a special influ- 
ence and value in cases of weak heart, with venous 
congestion of the organs; the rule as to dosage 
should be to give enough of it to produce a desired 
effect and to sustain this effect as long as necessary. 
Digitalis has been by turns condemned and 
praised. Theoretically, there are objections to its 
use; it increases arterial tension and does not 
relieve the pulmonary stasis, but it has the prop- 
erty of neutralizing the pneumococcus toxin, and 
has been given with good effect in large doses by 
Petresco, of Bucharest, and by Maragliano. The 
former gave 60 to 90 grains of the dried leaf daily. 
Maragliano gave 60 grains in infusion on the first 
day, repeated in lessening doses as the pulse 
becomes slower. But little support has, as yet, 
been given to this heroic procedure. 
For the relief of dyspnea and cyanosis, oxygen 
inhalations are usually employed. Their effect, 
however, is rarely what theoretic considerations 
would lead one to look for. In the severe cases 
in which such effect is most needed, the improve- 
ment in the character of the pulse, in the breathing 
and color of the lips, is temporary and not definite 
and complete. Still, it should always be used in 
such cases in conjunction with cardiac stimulants. 
Secondary pneumonia, as a rule, needs early 
alcoholic stimulants and a treatment modified by 
the preceding disease. In influenza pneumonia 
great irregularity and weakness of the heart are a 
greater danger than the condition of the lung, and 
call sometimes for strychnin and nitroglycerin in 
large doses until improvement is assured. In 
the pneumonia of typhus and typhoid fever and 
other secondary forms, hydrotherapy is much less 
efficient than in primary cases. Each complica- 
tion must be met, when possible, by treatment. 
Paracentesis may be needed in pericarditis and in 
pleurisy; and in empyema, section of the rib and 
drainage should be done as early as the diagnosis 
is made. 
A word should be said about bleeding in pneu- 
monia. As a rule of treatment, it received its 
death-blow from J. Hughes Bennett, and has not 
been since advised except as a resort in exceptional 
cases. In young, vigorous, and plethoric adults, 
with hyperpyrexia and a pulse of high tension, it 
may be beneficial in the first 48 hours. A small 
bleeding of 6 or 8 ounces has been advised in later 
stages, when there is cyanosis from overdistention 
of the right heart. The advocacy of venesection 
is only half-hearted, and its use is hedged about 
with so many restrictions that the rule of never 
bleeding, under any circumstances, is a safer one 
to follow. To restore faith in bleeding, even as a 
resort in exceptional cases, severe therapeutic 
trials are needed to prove the value of the favorable, 
but limited, individual support of this lost art. 
Instead of bleeding veratrum viride is highly 
praised by some. 
The "open air treatment" is beneficial. The 
patient must be well wrapped up and protected, 
and then allowed all the fresh air that is available. 
See Serum Therapy, and Vaccine Therapy. 
PNEUMONOKONIOSIS.-A general term indi- 
cating chronic disease of the lungs due to the in- 
halation of dust. Various names have been devised 
denoting the kind of dust causing the inflamma- PNEUMOTHERAPY 
POISONING 
tion; anthracosis or coal-miner's disease; siderosis, 
due to inhalation of iron dust; chalicosis, due to 
inhalation of mineral dust as of lead in lead miners' 
phthisis; lithosis or silicosis, stone-grinders' or pot- 
ters' phthisis, due to inhalation of particles of 
silica. Steel-grinders' phthisis is probably due to 
the particles of grindstone that are inhaled. 
Ganister disease is due to the dust of a siliceous 
rock. The dust particles, when they can no longer 
be disposed of by the natural protective agencies 
of the lungs, find their way into the peribronchial 
and periarterial lymph-spaces, where they set up 
an inflammation. This is characterized by a 
marked tendency to fibroid change, manifesting 
itself in the formation of hard, indurated nodules 
of various size. The fibroid areas may soften and 
break down, forming the so-called ulcers of the 
lung. Tuberculosis is prone to develop for the 
pulmonary lesions form a favorable nidus for the 
tubercle bacillus. 
PNEUMOTHERAPY.-See Tuberculosis (Pul- 
monary). 
PNEUMOTHORAX.-Air in the pleural sac. 
Etiology.-(1) Perforation of the pleura adjacent 
to a phthisical cavity; (2) perforation of the dia- 
phragm from malignant disease of the stomach 
or esophagus; (3) rupture of the lung by overstrain- 
ing; (4) rupture of empyema into the lung; (5) 
traumatism. 
Pathology.-There is effusion of air into the 
pleural sac. Coexisting with pneumothorax there 
is frequently an effusion of fluid into lung tissue- 
pneumohydrothorax, or pneumopyothorax, if 
purulent. The disease is usually unilateral, and 
may cause great displacement of the heart. The 
lungs are usually smaller than normal, due to the 
compression. 
Symptoms and Clinical Course.-Sudden pain, 
dyspnea, cyanosis, or collapse (subnormal tem- 
perature, rapid pulse, and cold extremities) may 
mark the onset of the disease. When slight, 
no special symptoms are produced in many cases. 
If pleurisy is present, the characteristic stitch in 
the side is pronounced. 
Physical Signs. Inspection.-There is bulging 
of the intercostal spaces, usually limited to one 
side, and displacement of apex-beat. 
Palpation shows diminished vocal (tactile) 
fremitus. 
Percussion-note is tympanitic over affected area, 
while immediately below this area dulness is 
elicited on account of presence of fluid. On 
turning patient to opposite side, the fluid 
gravitates and dulness may be replaced by 
tympany. 
Auscultation shows an absence of the respiratory 
murmur and normal vocal resonance. If due to 
rupture of phthisical sac, amphoric breathing is 
heard. At times metallic tinkling is detected. 
This is due to the dropping of fluid from above 
downward in an inclosed sac. 
Succussion detects splashing sound. 
Bell tympany is frequently present. It is 
elicited by placing the flat surface of a coin on the 
bare chest over affected area, and on being struck 
by another similar coin while listening over 
opposite side of chest in same relative position, 
a clear metallic sound is heard. 
Diagnosis.-Pneumothorax may be mistaken for 
a diaphragmatic hernia, but the stomach-tube 
would indicate the displacement. In dilated 
stomach the tympanitic note is continued down- 
ward to umbilicus, as well as upward. 
A large phthisical cavity simulates pneumo- 
thorax closely, and in many cases is identical with 
it. Usually phthisical cavities do not produce 
bulging of the intercostal spaces, are circumscribed, 
and the dulness is not movable. 
Prognosis is unfavorable. 
Treatment is symptomatic. If collapse threat- 
ens, strap the chest by means of adhesive plaster, 
and give hypodermics of whisky, strychnin 
(1/4 grain), and atropin (1/125 grain). Keep 
up bodily temperature by application of hot- 
water bag or hot blankets to extremities. 
PODAGRA.-See Gout. 
PODODYNIA.-Pain in the foot, and especially 
in the sole of the foot; the word is now 
usually limited to painful heel-a neuralgic con- 
dition about the heel, attended with little or 
no swelling, no discoloration, and no affection of 
the joints. The pains are very severe, though 
often limited to a very small area. It may be 
associated with rheumatism or gout, and with 
certain occupations requiring much standing. 
PODOPHYLLUM (May-apple).-The root of 
mandrake, P. peltatum. Its active principle is 
a resin which is official and contains two isomeric 
glucosids, podophyllotoxin and picropodophyllin; 
also podophyllinic acid and protocatechuic acid. 
Podophyllum probably contains the alkaloid 
berberin, which is found also in berberis, hydrastis 
and other plants. It is a tonic astringent, chola- 
gogue, and purgative, and is likely to produce 
nausea. It is recommended in remittent fever, 
bilious vomiting, and malarial jaundice. Dose 
of the root, 5 to 20 grains; of the resin, 1/8 to 1 
grain. P., Fluidextract. Dose, 2 to 20 minims. 
Pilulae Podophylli, Belladonnse et Capsici, have 
in each pill 1/4 grain of the resin, with 1/8 grain 
extract of belladonna and 1/2 grain capsicum. 
Dose, 1 to 2 pills. 
For constipation: 
I). Resin of podo- 
phyllin, 
Powdered aloes, 
Extract of nux 
each, gr. iij to vj 
vomica, 
Extract of bella- 
donna, 
each, gr. iv. 
Make 24 pills. One pill night and morning. 
POIKILOCYTOSIS.-See Blood. 
POISONING.-According to Reese, a poison is 
a substance capable of producing noxious and even 
fatal effects upon the system, no matter by what 
avenue it is introduced; and this, as an ordinary 
result in a healthy state of the body, and not by 
a mechanic action. 
Witthaus defines a poison, as "a substance which 
being in solution in, or acting chemically upon, 
the blood may cause death or serious bodily POISONING 
POISONING 
harm;" and a corrosive, as "a substance capable of 
causing death or injury by its chemical action 
upon a tissue with which it comes in direct con- 
tact." 
The most energetic poisons are hydrocyanic acid, 
potassium cyanid, nicotin, strychnin, phenol, and 
some reptile venoms. The poisons usually selected 
by poisoners for criminal purposes on others are 
those which produce effects resembling the symp- 
toms of natural disease, as arsenic, colchicin, 
tartar emetic, strychnin, morphin and aconite. 
Those generally chosen for suicidal purposes are 
such as may be most readily obtained by the 
laity, namely-phenol, morphin, illuminating gas, 
charcoal gas and potassium cyanid, the first being 
easily purchased for disinfecting purposes, while 
the last is commonly used in the arts. 
Diagnosis.-If diagnosis cannot be made from 
direct history, the process of exclusion should be 
instituted. 
The following lists have been compiled by 
Murrell, but no attempt has been made to render 
them complete, and they must be taken as being 
merely suggestive: 
The Patient is Dead.-Prussic acid (death in a 
few minutes at the outside); cyanid of potassium 
(usually kills very quickly); strong ammonia (may 
kill in a few minutes); carbonic acid gas (if pure, 
may kill almost at once); carbonic oxid; oxalic 
acid. Almost any active poison if given in a very 
large dose. 
The Patient is Comatose.-Opium; morphin; 
alcohol; chloral; chloroform; camphor. 
The Patient is in a Condition of Collapse.-Strong 
acids; alkalies; aconite; antimony; arsenic; to- 
bacco; lobelia. Most poisons cause collapse to- 
ward the last. 
The Patient is Delirious.--Belladonna (noisy, 
pleasing delirium, " the insane root that takes the 
reason prisoner"); hyoscyamus; stramonium; 
cannabis indica; alcohol; camphor. 
The Patient is Tetanized.-Nux vomica; strych- 
nin (think of vermin-killers); antimony; arsenic. 
There maybe a condition approaching tetanus from 
excess of pain-in poisoning by strong ammonia, 
for example. 
The Patient is Convulsed.-This may mean any- 
thing, the term being used vaguely. Antimony; 
arsenic; carbonic oxid; aconite. Strong acids, 
such as acetic or sulphuric, or strong alkalies, 
such as ammonia. 
The Patient is Paralyzed.-Physostigmin; conium 
(from below upward); gelsemium; aconite; arsenic; 
lead. 
The Pupils are Dilated.-Belladonna and atro- 
pin; hyoscyamus; stramonium; opium (in last 
stage); aconite; alcohol; chloroform (when taken 
in liquid form); conium. 
The Pupils are Contracted.-Opium (very strong- 
ly if a large dose); physostigmin; chloral (during 
sleep). 
The Skin Dry.-Belladonna and atropin; hyos- 
cyamus; stramonium. 
The Skin Moist.-Opium; aconite; antimony; 
alcohol; tobacco; lobelia. Almost any poison 
during the stage of collapse. 
Rash on the Skin.-Belladonna (resembles rash 
of scarlet fever); stramonium (much like the bella- 
donna rash); chloral (urticaria); arsenic (eczema, 
or may be like scarlet fever); antimony (pustular, 
like small-pox, but rare); opium (itching, followed 
by urticaria or papulous or roseolous patches, not 
common). Many other drugs excite cutaneous 
eruptions. For example, bromid of potassium 
and tar produce acne; copaiba, cubebs, and salic- 
ylic acid give rise to urticaria, and iodid of potas- 
sium may bring out a crop of petechiae. Croton 
oil, tartar emetic, sulphur, hydrastis, and arnica 
are well-known rash-producers when applied 
locally. Murrell has known croton chloral hy- 
drate, given for whooping-cough, to bring on 
urticaria. The discoloration of the skin resulting 
from the long-continued administration of silver 
requires no detailed mention. 
Odor of the Drug on the Breath.-Prussic acid; 
laudanum; alcohol (brandy, whisky, etc.); carbolic 
acid; acetic acid; ammonia; chloroform; creosote; 
iodin; phosphorus; camphor; nitrobenzol. The 
odor is not always a reliable guide; for example, 
laudanum is not uncommonly taken in porter. 
The Mouth and Tongue Dry.-Belladonna and 
atropin; hyoscyamus; stramonium; opium. 
Salivation.-Arsenic; ammonia; cantharides. 
Most drugs which produce a corrosive action on the 
mucous membrane of the mouth or esophagus. 
Mercury, jaborandi, and muscarin may also be 
mentioned. 
The Mouth Bleached.-Carbolic acid (mucous 
membrane white and hard); ammonia (epithelium 
coming off in flakes); potash; soda; nitric acid 
(white, soft, or yellow); corrosive sublimate. The 
numbness of the lips, mouth, and tongue, produced 
by aconite, will not be forgotten. 
The Patient is Vomiting.-Arsenic (brown, mixed 
with blood); antimony (white, stringy mucus, may 
be tinged with blood); digitalis (vomited matter 
has a grass-green color); aconite; colchicum; 
colocynth; ammonia (stringy saliva mixed with 
blood, fumes with hydrochloric acid); phosphorus 
(vomited matter luminous in the dark). 
The Patient is Purged.-Arsenic (continuous, 
with much pain, stools mixed with blood); anti- 
mony; corrosive sublimate (green in color, mixed 
with blood); cantharides (blood and slime); 
digitalis; colchicum; colocynth. 
The Patient is Suffering from Colic.-Lead (about 
navel, eased by pressure); copper; arsenic; colo- 
cynth. 
The Patient is Suffering from Cramp.-Arsenic; 
antimony; lead. 
The Drug was Given Hypodermically.-Morphin; 
atropin; strychnin. 
The Poison was Inhaled.-Ammonia; prussic 
acid; chloroform; ether; benzin; carbonic acid gas; 
carbonic oxid; coal-gas; sewer gas; cesspool gas and 
emanations. 
Poisons Commonly Used for Murder.-Arsenic; 
antimony; aconite; digitalis; opium; strychnin; 
prussic acid. 
Poisons Commonly Employed for Suicidal Pur- 
poses.-Opium and its preparations (commonest of 
all poisons); oxalic acid; rat paste; prussic acid; POISONING 
POISONING 
chloral; sugar of lead; strychnin. Patent medi- 
cines of all kinds unintentionally. 
Drugs Used Popularly as Abortifacients.-Ergot; 
rue; gin and pennyroyal; savin; bitter apple (colo- 
cynth, very popular); hickery pickery (hiera picra, 
or holy bitters, a mixture of 4 parts of aloes and 1 of 
canella bark); Spanish fly (cantharides); yew-tree 
tea; green tea in large quantities; quinin is often 
supposed to exert a specific action on the pregnant 
uterus; actsea racemosa (cimicifuga racemosa) is 
sometimes said to be an abortifacient, but there 
is very little truth in the statement; at all events, 
1/2 of a dram of the tincture 3 times a day is safe 
enough even in the later months of pregnancy. 
Pulsatilla is supposed to be capable of producing 
abortion, but this again rests on very imperfect 
evidence. "A handful of parsley chopped fine in a 
bottle of gin, allowed to stand a week, and a wine- 
glassful 3 times a day" (Hospital Patient). Parsley 
contains apiol, which is a powerful oxytoxic. 
Jaborandi was at one time supposed to exert a 
powerful action on the uterus, but the idea is now 
exploded. 
Indigenous Poisonous Plants.-Woody night- 
shade (Solanum dulcamara'); garden nightshade 
(Solanum nigrum); deadly nightshade (Atropa 
belladonna); aconite, monk's-hood, wolf's-bane or 
blue-rocket (Aconitum napellus); foxglove (Digitalis 
purpurea); spotted hemlock (Conium maculatum); 
arum (Arum maculatum); colchicum (Colchicum 
autumnale); bryony (Bryonia dioica); henbane 
(Hyoscyamus niger); fly agaric (Amanita muscaria); 
mezereon, or spruge olive (Daphne mezereum); 
laburnum (Cytisus laburnum); and a host of others. 
These will be found figured in Stephenson and 
Churchill's "Medical Botany," and in Bentley and 
Trimen's " Medicinal Plants." 
in their physiological action, and may be employed 
against each other as counterpoisons, to neutralize 
their effects upon the organism. They do their 
work in the blood and tissues, after absorption, 
and are especially available against poisons ad- 
ministered hypodermically, in which cases anti- 
dotes are usel'ess. Substances so employed are 
generally the active principles of plants, a few 
being chemicals, as oxygen and chloral. Antag- 
onistic measures include such proceedings as tend 
to neutralize the remote effects of poisons, as 
artificial respiration, faradism of the respiratory 
muscles, hot and cold applications, douching, con- 
stant motion or absolute repose, and the use of 
physiological (normal) salt solution to maintain 
circulation and increase elimination. 
Antidotes affect a poison, either physically or 
chemically or both, so as to remove it from the 
body or alter its character before absorption, and 
thereby prevent its toxic action upon the organ- 
ism. They do their work in the alimentary canal 
or in the respiratory passages, and are applicable 
to vegetable as well as mineral poisons, but they 
are not available against poisons administered 
hypodermically. Among them are emetics, ca- 
thartics, washes, injections, ligatures, poultices, 
the use of the stomach-pump, of tourniquets, etc., 
which are termed mechanical antidotes; and the 
chemical or true antidotes, which include albumin, 
milk, charcoal, soap, starch, oils, tannin, turpen- 
tine, acids, alkalies, potassium permanganate, 
carbonates, hydrates, sulphates, sodium chlorid, 
iodin, iron preparations, etc. 
Acids.-Vegetable acids, as acetic (or vinegar), 
citric (or lemon-juice), and tartaric, are employed 
as antidotes against the poisonous alkalies and 
alkaline carbonates. Sulphuric acid, well diluted 
with water, is antidotal to the soluble salts of 
barium and lead, with which it forms insoluble 
sulphates; also as a prophylactic against lead 
poisoning. 
Albumin is an ideal chemical antidote, being 
harmless, easily procured, and forming compounds 
(which are more or less insoluble) with most of the 
metallic salts, corrosive alkalies and mineral acids, 
as also with iodin bromin, chlorin, creosote, ani- 
lin, and alcoholic solutions of most of the alkaloids. 
It is especially suitable against inorganic poisons, 
and was recommended by Orfila for invariable use, 
even on the mere suspicion of poisoning. It 
should be well diluted, the whites of four eggs to a 
quart of lukewarm water; and should be followed 
by emetics and cathartics, as many of its com- 
pounds are soluble in an excess of itself. 
Ammonia, diluted, used by inhalation, is an 
efficient antidote against the vapors of corrosive 
acids and nitrobenzol, also against chlorin, bromin, 
and hydrocyanic acid. 
Calcium hydroxid and carbonate, in the form of 
lime-water, chalk, eggshells or powdered oyster- 
shells are used against acids, both mineral and 
organic, and especially against oxalic acid and the 
acid oxalates, which they neutralize and convert 
into the insoluble calcium oxalate. 
Carbonates and bicarbonates of sodium and 
potassium are employed against most of the 
General Principles of Treatment (Potter). 
(1) Lose no time. (2) Use the best remedy 
obtainable at once. (3) Get rid of the poison. 
(4) Stop its action. (5) Remedy the mischief 
already done. (6) Fight against the tendency to 
death (Tanner). In the treatment of poisoning, 
whether by mineral or vegetable substances, if 
the poison is known the first indication is to ad- 
minister the proper chemical antidote, so as to 
render it harmless or comparatively so. Next, 
the stomach should be emptied and washed out, 
lest the newly-formed compound be absorbed after 
a time; also to remove any poison which may have 
escaped the action of the antidote. Next, the 
appropriate antagonist should be administered, to 
counteract the effects of such portion of the poison 
as may have been absorbed. Lastly, such antag- 
onistic measures should be employed as may sustain 
the action of any organic function showing signs 
of failure. In most cases of alkaloidal poisoning 
absorption has proceeded so far before professional 
assistance is obtained that antidotes are of no 
value, hence reliance can be placed only upon the 
physiological antagonist and such supporting 
measures as will tend to maintain vitality until the 
poison can be eliminated by the natural channels. 
Antagonists are agents which oppose each other POISONING 
POISONING 
poisonous metallic salts, especially those of zinc, 
which they immediately decompose, forming in- 
soluble basic compounds; also against iodin, 
bromin, and potassium dichromate, forming the 
neutral chromate with the latter and harmless 
salts with the former. They are useful in dilute 
solution against acids, but are less-easily tolerated 
than magnesium sulphate. They are contrain- 
dicated in poisoning by oxalic acid, with which 
they form dangerous compounds. Ammonium 
carbonate, in dose of 5 grains, administered hypo- 
dermically in the vicinity of wounds caused by 
poisoned arrows, was repeatedly used by Dr. 
Parke, the surgeon of Stanley's last expedition in 
Africa, with entire success in saving life when it 
was employed immediately after the injury. Per- 
sons so wounded, if they were at too great a dis- 
tance to receive this treatment, invariably died 
within a short time. 
Cathartics are generally employed after the use 
of a chemical antidote, to remove the compounds 
formed thereby from the intestinal canal. The 
best are castor oil, croton oil, senna, and magnesium 
sulphate (Epsom salt). Castor oil protects the 
mucous membrane and obstructs absorption, but 
is contraindicated in poisoning by phosphorus, 
phenol, copper salts, or cantharis, the absorption 
of which is aided by oils and fats. Croton oil is 
rapid and powerful in the dose of from 1 to 5 
minims, in a bread pill. Magnesium sulphate, in 
the dose of 1 to 4 ounces, well diluted, is of special 
service in chronic lead poisoning and to remove 
antidotal compounds from the intestines. Senna, 
gamboge, and other drastics are the best cathar- 
tics in narcotic poisoning. 
Charcoal has some antidotal value against many 
alkaloids, the metallic salts, and phosphorus, 
slowing their toxic action and postponing their 
effects, probably by a protective action upon the 
gastric walls. It has the valuable property of 
absorbing gases, but enters into no fixed compound 
with any mineral or vegetable poison. Fresh 
animal charcoal is the best, though wood charcoal 
is efficient, but in less degree. 
Chlorin in the form of chlorin water, Labarra- 
que's solution, or Javelle water, is employed ex- 
ternally as an antidotal wash for snake-bites and 
other poisoned wounds; also, well diluted, intern- 
ally against alkaloids and other vegetable and 
animal poisons; and as a spray for antidotal 
inhalation against coal gas (carbonic oxid), am- 
monia, phosphoreted and sulphureted hydrogen, 
also hydrocyanic acid. 
Copper carbonate, in dose of 3 to 6 grains, with 
sugar and water, preceded and followed by an 
emetic, is recommended in phosphorus poisoning, 
being supposed to coat the particles of phosphorus 
first with a layer of copper phosphide and then 
with one of copper itself, thus preventing their 
solution in the fluids of the stomach. 
Emetics, when employed, should be used with- 
out delay. They are often rendered needless by 
vomiting induced by the poison itself, or by the 
free use of diluent drinks; and are contraindicated 
when there is severe corrosion of the alimentary 
canal or when abdominal inflammation exists. 
The best emetics are: Zinc sulphate, for stomachal 
administration, being non-nauseating, 20 to 30 
grains in water, 5 grains for children. Apomor- 
phin, 1/16 to 1/8 grain, hyjpodermically, when 
narcosis prevents the use of emetics by the mouth. 
It should be administered hypodermically, as it is 
very uncertain in action when given otherwise. 
The following may be used: Copper sulphate, 1 
to 5 grains in water; ipecac, in powder; emetin, 
1/12 to 1/3 grain; tartar emetic, 1 1/2 grain, acts 
slowly and is depressant; turpeth mineral; cadmium 
sulphate; sodium chlorid (common salt), 2 tea- 
spoonfuls in a pint of water; mustard, 2 teaspoon- 
fuls in a cup of warm water; also olive oil, soap-suds, 
snuff, melted fats, and tickling the fauces with the 
finger or a feather. Sodium chlorid as an emetic is 
contraindicated in poisoning by tartar emetic or 
corrosive sublimate, and so also are oils and fats 
and substances containing them, in poisoning by 
phosphorus, cantharis, phenol or copper salts. 
Gelatin is of especial value against iodin, bromin 
and the alums, but requires too much time for its 
preparation, as it should be broken up, soaked in 
water for half an hour and reduced to the consis- 
tency of honey. 
Gluten is of value against corrosive sublimate, 
but is less so than albumin and is not easily 
obtained. 
Gum arabic, in the form of mucilage, is chiefly 
used as a protective against corrosive poisons, and 
has been recommended in copious draughts 
against poisoning with the bismuth salts. 
lodin, in very dilute solution, is used as an an- 
tidote against alkaloids and their salts, other 
vegetable poisons, and snake-venom. All its com- 
pounds are more or less soluble and toxic, and 
must therefore be removed from the system as 
soon as possible. Bouchardat's antidote for veget- 
able poisons consists of 3 grains of iodin, 30 grains 
of potassium iodid and 11 ounces of distilled water. 
The dose, which is from 1 1/2 to 3 ounces, should 
be repeated frequently. 
Iron.-The hydroxid Fe (OH)3, is by far the best 
antidote to arsenic in solution or in a soluble form, 
as it combines with the latter to form a ferrous 
arsenate, and also protects the gastrointestinal 
mucous membrane against the local action of the 
poison. In the proportion of 10 parts to one 
of arsenic the union is very complete, but its 
union with the salts of arsenic is limited even when 
it is in great excess, though much more effectual 
if there is added to it a small amount of ammonia 
or other caustic alkali, or if the basic ferric acetate 
is mixed with it. For the preparation of the offi- 
cial arsenic antidote see Arsenic. Dialyzed iron, 
saccharated iron, and the basic ferric acetate have 
all been used with more or less success in arsenic 
poisoning. 
Magnesia (MgO), is obtained by heating mag- 
nesium carbonate, which is a compound of the 
hydroxid and carbonate of magnesium with water. 
When the carbonate is heated at a low tempera- 
ture it becomes calcined, losing CO2 and H2O; 
then mixed with 25 times its weight of warm water 
it becomes gelatinized, in which condition it is 
best for antidotal purposes, in doses of from 11/2 POISONING 
POISONING 
to 2 ounces, at short intervals for a few doses, then 
at longer intervals. An excess does no harm, but 
rather benefits the patient by its cathartic action. 
Magnesia is the most efficient antidote against acids 
and the acid salts, also against oxalic acid and the 
acid oxalates, in the absence of the calcium anti- 
dotes therefor. It is also valuable against arsenic, 
phosphorus, mercury, corrosive sublimate and 
other metallic salts in solution, precipitating the 
corresponding oxids or basic salts. 
Milk is a good substitute for albumin, its anti- 
dotal action being nearly the same in range and due 
to its casein, albumin and free alkali. It is par- 
ticularly valuable against metallic salts, corrosive 
acids and alkalies (especially ammonia) and the 
alkaline earths, but it is contraindicated when 
fatty antidotes are to be avoided, by reason of its 
richness in fat. 
Oils and Fats are efficient against the corrosive 
acids and alkalies, the metallic oxids and salts; but 
are contraindicated in poisoning by phosphorus, 
cantharis, phenol, or copper salts, the absorption 
of which they promote. With the caustic alkalies 
they unite to form soaps, liberating glycerin; they 
are inferior to albumin against the metallic salts, 
and as their action is slow they are less efficient 
than acids against alkalies. Those used are olive, 
cotton-seed, linseed and almond oils, also melted 
butter and lard. 
Potassium ferrocyanid, given in doses of 30 to 
60 grains in water, is of special value against the 
copper salts, but albumin is equally efficient and 
more easily obtained. 
Potassium permanganate is the best antidote 
against organic poisons, if used promptly, before 
absorption has taken place, as it rapidly destroys 
them by oxidation. It has been used successfully 
against morphin and strychnin salts and phos- 
phorus in the stomach, and locally for snake- 
poison. 
Soap, as Castile soap, dissolved in 4 times its 
bulk of hot water, to make "suds," and given by 
the cupful, is one of the most efficient antidotes 
against corrosive acids and metallic salts, espe- 
cially corrosive sublimate, potassium dichromate, 
and salts of tin and zinc. It is inferior to albumin 
against these, but is preferred to caustic alkalies 
against acids, as of itself it has no corrosive action. 
It should not be used against alkalies. 
Sodium borate (borax), in milk (5 percent), is 
recommended as a convenient and efficient gen- 
eral antidote; acting by the alkaline effect of the 
sodium, which precipitates metallic hydroxids 
from solutions of their salts, and also precipitates 
alkaloids from their salts. The milk acts by virtue 
of its albumin, forming albuminates and casein 
compounds with the poisons. The stomach 
should always be evacuated after the use of this 
agent, as the compounds formed are soluble in the 
digestive fluids. 
Sodium chlorid (common salt), in dilute solution, 
is the best antidote against the silver salts, con- 
verting them into the insoluble chlorid of silver. 
It may be given with albumin, which is also a very 
efficient antidote in this form of poisoning. 
Sodium thiosulphate in doses of 15 grains, in very 
dilute solution and frequently repeated, is a valu- 
able antidote against bleaching powder (calcium 
hypochlorite), Labarraque's solution (sodium 
hypochlorite), and Javelle water (potassium 
hypochlorite), which it reduces to chlorids, itself 
undergoing oxidation to the sulphate. 
Starch, in paste, 1 to 15 of water, is the antidote 
for iodin and bromin, with which it forms com- 
pounds which are almost harmless. It has some 
value against corrosive acids, corrosive sublimate, 
and zinc and copper sulphates, but it is not so 
efficient as albumin, which is preferred for these 
poisons as well as for iodin, since it has a greater 
affinity than starch has therefor. 
Stomach pump and stomach siphon are efficient, 
and do not weaken the patient as emetics do, but 
they are not always available, and cannot be used 
when there is corrosion of the stomach or esoph- 
agus, for fear of perforation. Washing of the 
stomach at regular intervals is a measure of great 
importance in the case of soluble poisons, some of 
which are excreted into the stomach. These ap- 
pliances are almost useless when the poison is in 
solid form and in large pieces (as meat, sausage, 
fish, cheese). 
Sulphates of magnesium and sodium (Epsom 
and Glauber's salts), the soluble sulphates, are 
particularly efficient against phenol and the salts 
of barium and lead. 
Tannin (tannic acid), precipitates the alkaloids 
and their salts, with which it forms compounds 
(tannates), which, though comparatively insoluble 
are not entirely inactive, and should be removed 
at once from the alimentary canal by emetics 
and drastic purgatives. It acts well against 
many metallic salts, though inferior to albumin 
for these, except against tartar emetic, which 
albumin does not affect, but tannin renders harm- 
less. It is given in doses of 15 to 45 grains in a 2 
percent solution, every quarter of an hour; and if 
combined with about 10 percent of its weight of 
iodin its antidotal effect on vegetable poisons is 
greatly increased. If not itself obtainable, decoc- 
tions or infusions of substances containing it may 
be used, as tea and coffee, nut-galls, kino, rhatany, 
catechu, and the barks of oak, willow and cinchona. 
Turpentine, after long exposure to the air, 
therefore containing much oxygen, is one of the 
antidotes against phosphorus. It should be 
administered immediately after the ingestion of 
that poison, alone or in hot water, and in quantity 
100 times that of the phosphorus supposed to be 
present. 
Antidote bag, designed by Martindale, of Lon- 
don, contains the following-named articles, labeled, 
with directions for use, viz.: Dialyzed iron, syrup 
of chloral, chloroform, spirit of chloroform, cal- 
cined magnesia, aromatic spirit of ammonia, oil 
of turpentine, acetic acid, tincture of digitalis, 
tannic acid, amyl nitrite, zinc sulphate, ipecac- 
uanha, potassium bromid, potassium permanga- 
nate. Solution of ferric sulphate, 40 c.c. in 125 
c.c. of water. Magnesia, in solution, 10 grams in 
750 c.c. of water, in a bottle of 1000 c.c. capacity. 
These two, mixed together, make the official 
antidote against arsenic. Also a hypodermic POISONS 
syringe, and solutions or pellets therefor of mor- 
phin sulphate, atropin sulphate, apomorphin 
hydrochlorid, pilocarpin nitrate, strychnin nitrate. 
General antidotes have been devised for use when 
the nature of a poison is unknown, with the object 
of a "shot-gun prescription," intended to hit some- 
thing. One of the best is Jeaunel's, composed as 
follows: Liquor ferri sulphatis (specific gravity, 
1.45), 2 1/2 ounces; magnesium oxid, 2 ounces; 
carbo animalis, 1 ounce; aqua, 20 ounces. These 
ingredients should be kept separate-the solution 
of the sulphate in one vessel, the others together. 
When needed, the former should be added to the 
latter and violently agitated. Dose, 11/2 to 3 
ounces. This is a perfect antidote to arsenic, zinc, 
digitalin. It delays the action of salts of copper, 
morphin, and strychnin, and slightly influences 
compounds of mercury. It is valueless for cyanid 
of mercury, tartar emetic, hydrocyanic acid, phos- 
phorus, or the caustic alkalies. 
Bellini, of Florence, considers the iodid of starch 
a valuable antidote to alkaline sulphide, earthy 
sulphids, vegetable and caustic alkalies, and am- 
monia. In the first two cases he considers it 
superior to all other antidotes. 
A fresh mixture of the sulphids of iron and 
sodium with magnesia is said to be a perfect anti- 
dote for copper salts, corrosive sublimate, and 
mercuric cyanid. If the nature of the poison is 
entirely unknown, a harmless yet effectual antidote 
in most cases is one composed of equal parts of 
magnesia, wood charcoal and the ferric hydroxid, 
given freely in plenty of water. 
The following table of poisons includes the 
names of the various poisonous substances, the 
particularly prominent symptoms, the mode of 
producing death, and the antidotes and general 
treatment. Tables showing the anatomic distri- 
bution of lesions in death from poisoning and the 
lesions characteristic of the more important poisons 
are given under Poisoning (Medicolegal Duties in 
Fatal Cases). 
POISONS 
POISONS, TABLE OF. 
Name. 
Symptoms of Poisoning. 
Mode of 
Producing Death. 
Treatment and Antidotes. 
Acetanilid 
Cyanosis; peculiar discoloration of the 
blood due to formation of methemoglobin. 
Sudden cardiac fail- 
ure. 
Strychnin, oxygen, and 
warmth; heartrstimulants. 
Acetic Acid. See Acid, Acetic. 
Acetphenetidin. See Phenacet 
in. 
Acid, Acetic 
Vomiting, purging; pain in the stomach, 
foul breath. 
Asphyxia 
Alkalies; soap; demulcent 
drinks; opium. 
Acid / Arsenous. 1 See 
' I Arsenic. J Arsenic. 
Acid, Boric 
Nausea, vomiting, erythema, rapid, feeble 
pulse, collapse. 
Cardiac paralysis. 
Acid, Carbolic (Phenol) 
Immediate burning pain from mouth to 
stomach; giddiness, loss of consciousness, 
collapse; subnormal temperature; par- 
tial suppression of urine, which is dark in 
color; pupils very much contracted; 
characteristic odor. 
Respiratory and 
cardiac paralysis. 
Wash out stomach with 
alcohol and water; hypo- 
dermic of apomorphin; 
magnesium sulphate; atro- 
pin. 
Acid, Chromic 
Yellow stains; abdominal pain; vomiting 
and purging; collapse. 
Cardiac paralysis .. 
Evacuate; chalk, milk, or 
albumin; demulcent drinks. 
Acid, Hydrochloric (Muri- 
atic). 
Pain throughout digestive tract; vomiting, 
feeble pulse, clammy skin, collapse; es- 
chars externally; yellow stains on cloth- 
ing, but none on skin. 
Alkalies; demulcent drinks; 
oil; stimulants (intrave- 
nous injection). 
Acid, Hydrocyanic (Prussic). 
Sudden unconsciousness, slow labored res- 
pirations, slow pulse, staring eyes, pur- 
ple face, general convulsions, then relaxa- 
tion and collapse, odor of peach kernels; 
death may be almost instantaneous. 
Asphyxia 
Stomach tube if possible. 
Dilute ammonia; opium, to 
relieve pain; alternate cold 
and warm affusions; atro- 
pin and heart-stimulants; 
artificial respiration. 
Acid, Lactic 
Violent irritation of alimentary canal 
Alkalies and demulcents. 
Acid, Nitric 
Yellow stains on skin; otherwise similar 
to Acid, Sulphuric. 
Alkalies; demulcents; soap; 
stimulants. 
Acid, Nitrohydrochloric. 
Same as Acid, Nitric. 
Acid, Oxalic 
Hot, acrid taste; burning, vomiting, col- 
lapse; sometimes general paralysis, numb- 
ness and stupor. 
Paralysis of respi- 
ration and of heart. 
Lime or chalk. POISONS 
POISONS 
Name. 
Symptoms of Poisoning. 
Mode of 
Producing Death. 
Treatment and Antidotes 
Acid, Prussic. See Acid, Hydr 
ocyanic. 
Acid, Pyrogallic 
Vomiting, diarrhea, rigors, fever, black 
urine, great dyspnea. 
Formation of throm- 
bi. 
Mineral acids; alkalies; salts 
of iron. 
Acid, Salicylic 
Mydriasis; quick and deep respiration; 
delirium; dyspnea; lessened arterial pres- 
sure; deafness; olive green urine. 
Respiratory paral- 
ysis. 
Acid, Sulphuric 
Black stains; pain throughout digestive 
tract, vomiting often of tarry matter, fee- 
ble pulse, clammy skin, profuse and 
bloody salivation. 
Asphyxia 
Chalk; magnesia; soap; de- 
mulcent drinks. 
Acid, Sulphurous 
Cough, bloody expectoration, pulmonary 
inflammation. 
Air; cold to head; artificial 
respiration; bleeding. 
Acid, Tartaric 
Pain in abdomen; vomiting, etc 
Magnesia; lime; soap. 
Aconitum napellus (Monks- 
hood). 
Aconite. 
Sudden collapse, slow, feeble and irregular 
pulse and respirations, tingling in the 
mouth and extremities, giddiness, great 
muscular weakness, sometimes pain in the 
abdomen, pupils generally dilated, but 
may be contracted, marked anesthesia of 
skin, mind clear, convulsions at times. 
Asphyxia 
Tannic acid solution for 
washing out stomach; digi- 
talis, atropin, and stimu- 
lants; artificial respiration; 
warmth and friction. 
Actsea spicata (Baneberry).... 
Vomiting; diarrhea; cardiac depression; 
faintness; dizziness; foul breath; dryness 
of pharynx. 
Cardiac paralysis.. 
Heart-stimulants. 
Agaricus. See Fungi. 
Alcohol 
Confusion of thought, giddiness, tottering 
gait, slight cyanosis, narcosis from which 
patient can be aroused; full pulse; deep 
stertorous breathing; injection of eyes, 
dilatation of pupils, low temperature, 
convulsions, coma, death often hours or 
even days after apparent recovery. 
Paralysis of heart.. 
Evacuate stomach; coffee; 
battery; amyl nitrite; hot 
and cold douches. 
Aloes 
Tenesmus, weight in pelvis, profuse diar- 
rhea. 
Amanita muscaria (Truffles). 
See Fungi 
Ammonium and its com- 
pounds. 
Intense gastroenteritis, often with bloody 
vomiting and purging; lips and tongue 
swollen and covered with detached epi- 
thelium; violent dyspnea; characteristic 
odor. 
Asphyxia 
V egetable acids; demulcents. 
Amygdalus communis (Bitter 
Almond). 
Similar to Acid, Hydrocyanic, q. v. 
Amyl Nitrite 
Throbbing headache, flushed face, sense of 
heat, tumultuous heart's action; dimin- 
ished sensibility, mobility and reflexes. 
Paralysis of respira- 
tory centers. 
Evacuate; air; recumbent 
position; artificial respira- 
tion; stimulants; strych- 
nin; ergot; digitalis. 
Amylene Hydrate 
Sleep and coma 
Paralysis of me- 
dulla. 
Remove vapor; air; stimu- 
lants; artificial respiration. 
Anilin 
Giddiness, apparent intoxication, sweating, 
blue color of mucous membrane of mouth; 
odor of anilin; coma. 
Asphyxia 
Removal of cause; stimula- 
tion; oxygen; artificial res- 
piration. 
Antifebrin. See Acetanilid. 
Antimony and its compounds. 
Metallic taste, violent vomiting becoming 
bloody; feeble pulse, pain and burning in 
the stomach, violent serous purging, be- 
coming bloody; dysphagia; cramps in 
extremities; thirst; great debility; some- 
times prostration, collapse, unconscious- 
ness, and convulsions without vomiting 
or purging. 
Paralysis of the 
heart. 
Tannic acid; demulcent 
drinks; opium; alcohol; 
external heat. 
POISONS, TABLE OF. POISONS 
POISONS 
POISONS, TABLE OF. 
Name. 
Symptoms of Poisoning. 
Mode of 
Producing Death. 
Treatment and Antidotes 
Antipyrin (Phenazori) 
Headache, nausea, vomiting, a rash like 
that of measles, vertigo, drowsiness, deaf- j 
ness, confusion of ideas, cyanosis, collapse. 
Recumbent position: 
warmth; strychnin; stimu- 
lants; oxygen; artificial 
respiration. 
Apocynum androsalmifolium 
(Dogsbane). 
Vomiting, nausea, drowsiness 
Evacuate; stimulants. 
Apomorphin 
Violent vomiting, paralysis of motor and 
sensory nerves, delirium, depression of ; 
respiration, heart-depression. 
Cardiac failure 
Cardiac and respiratory 
stimulants. 
Aristolochia clematis (Birth- 
wort) . 
Nausea; griping pains in the bowels; vomit- 
ing; dysenteric tenesmus. 
Evacuate; demulcent drinks. 
Arnica montana (Leopards- 
bane). 
Transient excitement, headache, uncon- 
sciousness, pupils dilated, paralysis of the 
nervous system, collapse. 
Paralysis of the ner- 
vous system. 
Cardiac stimulants. 
Arsenic and its compounds. . 
Violent burning pain in the stomach, retch- 
ing, thirst, purging of blood and mucus 
with flakes of epithelium; tenesmus, burn- 
ing in the urinary organs with suppression 
of urine; sense of constriction with dry- 
ness in throat; pulse small and frequent. 
Hydrated sesquioxid of iron; 
precipitated carbonate of 
iron; emetics; castor oil; 
demulcents. 
Artemisia absinthium (Ab- 
sinthe) . 
Tremor, stupor, epileptiform convulsions, 
involuntary evacuations, stertorous 
breathing. 
Emetics; stimulants; demul- 
cents. 
Aspidium (Male Fern) 
Vomiting, purging, great pain in the abdo- 
men, collapse; giddiness; coma; amauro- 
sis; cramp in extremities. 
Evacuate; stimulants. 
Atropa belladonna (Deadly 
Nightshade). 
Atropin. 
Belladonna. 
Homatropin. 
Heat and dryness of the mouth and throat; 
pupils widely dilated, scarlet rash; quick 
pulse, at first corded, later feeble; rapid 
respirations, early strong, late shallow 
and feeble; retention of urine; sometimes 
convulsions, collapse, and paralysis; sup- 
pression of saliva, difficulty in swallow- 
ing; great thirst, indistinct vision, noisy 
delirium; skin dry. 
Paralysis of the 
heart. 
Evacuation of stomach and 
bladder; stimulants: coffee; 
pilocarpin; artificial res- 
piration; physostigmin 
may be of benefit. 
Barium and its compounds... 
Pain in the abdomen, purging, vomiting, 
feeble pulse, short and labored breathing, 
cramps, convulsions, collapse. 
Evacuate; Glauber's or Ep- 
som salts; dilute sulphuric 
acid; warmth. 
Bitter Almond (Amygdalus).. 
Similar to Acid, Hydrocyanic, q. v. 
Bittersweet. See Solanum. 
Bloodroot. See Sanguinaria. 
Boric Acid. See Acid, Boric. 
Bromin and its compounds... 
Respiration and heart's action lessened; 
reflexes sluggish; diminished sensibility; 
motility and sexual function impaired; 
acne; fetid breath; mental foculties im- 
paired. 
Cardiac and muscu- 
lar paralysis. 
Heat; stimulants; digitalis; 
ergot; atropin; strychnin; 
artificial respiration. 
Brucin. See Strychnin. 
Bryonia dioica (Bryony) 
Giddiness, delirium, vomiting, diarrhea, 
with watery motions, dilated pupils, 
coma. 
Heart-depression... 
Emetics; mustard; salt: ipe- 
cacuanha; stimulants, 
freely. 
Caffea arabica. See Caffein. 
Caffein. 
Burning pain in the throat, giddiness, 
faintness, nausea, numbness, abdominal 
pain, great thirst, dry tongue, tremor of 
extremities, diuresis, weak pulse, cold 
skin, collapse. 
' Paralysis of respir- 
। ation. 
Emetics; stimulants; 
warmth; morphin and atro- 
pin. 
Calabar Bean. See Physostig 
ma. POISONS 
POISONS 
POISONS, TABLE OF. 
Name. 
Symptoms of Poisoning. 
Mode of Treatment and Antidotes. 
Producing Death. I 
Calcium. See Lime. 
Camphine. See Turpentine. 
Camphor 
Characteristic odor; languor, giddiness, 
disturbance of vision, delirium, convul- 
sions, clammy skin, smarting in the uri- 
nary organs, pulse quick and weak; no 
pain, no vomiting, no purging. 
Asphyxia 
Evacuate stimulants; 
warmth; hot and cold 
douches. 
Cannabis indica {Indian 
Hemp). 
Pleasurable intoxication; sense of prolon- 
gation of time; anesthesia with loss of 
strength especially in legs; rapid pulse; 
increased sexual desire; pupils dilated; 
heavy sleep. 
Strychnin; faradization; 
evacuate; stimulants. 
i 
Cantharis vesicatoria {Span- 
ish Fly). 
Cantharides. 
Burning in mouth and stomach, vomiting 
and purging, soon becoming bloody, and 
abdominal tenderness, tenesmus, the 
vomit containing shining particles of the 
powder; incessant desire to urinate, but 
only a little blood or albuminous urine 
passed at each attempt; priapism, abor- 
tion, convulsions, coma, and insensibility. 
Paralysis of the re- 
spiratory centers. 
Evacuate stomach; demul- 
cent drinks; morphin; hot 
bath for the strangury; 
anesthetics may be neces- 
sary for the pain. 
Carbolic Acid. See Acid, Car- 
bolic. 
Carbon Disulphid 
Headache, vertigo, nervous excitement, 
anesthesia with great muscular rigidity, 
characteristic odor of breath, urine, and 
feces. 
Paralysis of the re- 
spiratory centers 
and of the heart. 
Evacuate; stimulants; 
warmth; artificial respira- 
tion. 
Castor-oil. See Ricinus. 
Chelidonium majus {Celan- 
dine) . 
Catharsis; vomiting; cardiac debility 
Paralysis of the 
heart. 
Evacuate; heart-stimulants. 
Cherry Laurel. See Prunus. 
Chloral Hydrate 
Deep sleep, loss of muscular power, lividity, 
reflexes diminished, pulse weak, respira- 
tions slowed, pupils contracted during 
sleep, but dilated on waking, temperature 
low. 
Arrest of respira- 
tion or paralysis 
of the heart. 
Evacuate; heat to the ex- 
tremities; massage; coffee 
by the rectum; strychnin; 
amyl nitrite; artificial res- 
piration. 
Chlorin 
Irritation of the throat, cough, tightness 
across chest, inability to swallow. 
Asphyxia 
Air; steam-inhalations; di- 
lute ammonia-inhalations; 
ether or chloroform. 
Chlorodyne. See Opium. 
Chloroform 
Two methods of introduction, inhalation 
and swallowing; symptoms in latter case 
delayed. 1. Slight stimulation; 2. ex- 
citement and incoherence; 3. insensibility 
and relaxation. 
Usually paralysis of 
the heart. 
Draw tongue forward; air; 
artificial respiration; fara- 
dic current; hot and cold 
douches; amyl nitrite; 
atropin; evacuation of 
stomach if chloroform has 
been taken by mouth. 
Chromium and its compounds. 
See Acid, Chromic. 
Cicuta maculata {American 
Hemlock). 
Similar to those of Conium, q. v. 
Cicuta virosa (Water Hem- 
lock) . 
Similar to those of Conium, q. v. 
Citric Acid. See Acid, Citric. 
Coal-gas 
Headache, giddiness, loss of muscular pow- 
er, unconsciousness, pupils dilated, breath- 
ing labored, coma, odor of gas. 
Asphyxia 
Fresh air; artificial respira- 
tion ; ammonia; stimulants; 
oxygen; coffee; hot and 
cold douches. 
Cocain 
Faintness, giddiness, nausea; pulse small, 
rapid, and intermittent; severe prostra- 
tion; respiration slow and feeble. 
Spasm of heart and 
muscles of respira- 
tion. 
Stimulants; amyl nitrite; 
artificial respiration. POISONS 
POISONS 
POISONS, TABLE OF. 
Name. 
Symptoms of Poisoning. 
Mode of 
Proddcinq Death. 
Treatment and Antidotes 
Cocculus indicus (Fish-berries) 
Picrotoxin. 
Nausea, vomiting, muscular debility, som- 
nolence, sometimes convulsions, occasion- 
ally scarlatinal rash. 
Paralysis of heart in 
diastole. 
Evacuate; chloral hydrate; 
bromid of potassium. 
Colchicum autumnale (Mea- 
dow Saffron). 
Not unlike those of malignant cholera; 
griping pain in the stomach, vomiting and 
continuous purging of seromucous ma- 
terial; intense thirst, muscular cramps, 
great prostration; pinched face, profuse 
perspiration, collapse; dilated pupils; 
pain in the extremities. 
Paralysis of the re- 
spiratory centers. 
Evacuate; tannic or gallic 
acid; demulcent drinks; 
stimulants; morphin. 
Colocynth 
Persistent vomiting and purging, exhaus- 
tion, cold extremities, weak pulse, 
collapse. 
Evacuate; camphor, opium; 
stimulants; demulcent 
drinks; warmth. 
Conium maculatum (Hem- 
lock) . 
Weakness of the legs, gradual loss of all 
voluntary power, nausea, ptosis, pupils 
dilated, inability to speak or swallow. 
Paralysis of the re- 
spiratory muscles. 
Evacuate; tannic or gallic 
acid; stimulants; warmth; 
artificial respiration; atro- 
pin. 
Convallaria majalis (Lily of 
the Valley). 
Similar to Digitalis, q. v 
Cardiac paralyzant; 
arrests heart in 
systole. 
Convolvulus jalapse. See Jal 
ap. 
Convolvulus scammonii. 
Copper and its salts 
Metallic taste in mouth, griping and colicky 
pains, nausea and vomiting, purging with 
straining, jaundice, hurried breathing, 
small, rapid pulse, weakness, thirst, 
giddiness, coma. 
Evacuate; barley-w a t e r ; 
morphin; poultices to abdo- 
men. 
Coriaria myrtifolia (Myrtle- 
leaved Sumach). See Su 
mach. 
Creosote . 
Similar to Acid, Carbolic, q. v. 
Croton tiglium (Croton-oil)... 
Intense pain in the abdomen, vomiting, 
purging, watery stools, pinched face, 
small and thready pulse, moist skin, 
collapse. 
Evacuate; demulcent drinks; 
camphor; stimulants; mor- 
phin; poultices to abdo- 
men. 
Cubebs 
Nausea, vomiting, colicky pains; in some 
cases purging; in some an eruption resem- 
bling urticaria. 
Cucumis colocynthis. See 
Colocynth. 
Curare (Indian War-poison).. 
Complete paralysis of the voluntary mus- 
cles, slowing of the heart, gradually dimin- 
ished respiration. 
Arrest of the respi- 
ratory movements. 
Artificial respiration; stimu- 
lants; ligate and wash 
wound; evacuate bladder 
frequently. 
Cyanogen and its compounds. 
Similar to Acid, Hydrocyanic, q. v. 
Cyclamen europaeum (Sow- 
bread) . 
Inflammation of the alimentary canal; 
bloody stools; cold sweats; convulsive 
movements. 
Evacuate; opium; poultices 
to abdomen. 
Cytisus laburnum (Laburnum). 
Come on rapidly; purging, vomiting, great 
restlessness; drowsiness and insensibility, 
convulsive twitchings. 
Asphyxia 
Evacuate; stimulants; cof- 
fee per rectum; hot and 
cold douches. 
Daphne gnidium (Sponge 
Flax). 
Pain; vomiting; purging 
Evacuate; demulcent drinks; 
heart-stimulants. 
Daphne mezereum (Meze- 
reon). See Mezereon. 
Datura stramonium (Thorn- 
apple, J amestown Weed). 
Symptoms and treatment similar to those 
of Atropin, q. v. 
Delphinium staphisagria (Sta- 
vesacre). See Staphisagria. POISONS 
POISONS 
POISONS, TABLE OF. 
Name. 
Symptoms of Poisoning. 
Mode of 
Producing Death, j 
Treatment and Antidotes. 
Digitalis purpura (Fox-glove).. 
Purging, with severe pain, violent vomit- 
ing; vertigo; feeble pulse, although heart's 
action is tumultuous; headache; lethargy 
followed by delirium and convulsions; 
eyes prominent, pupils dilated, sclera 
blue; skin cold, coma. 
Heart-paralysis.... 
Evacuate; tannic and gallic 
acids; stimulants; aconite; 
recumbent position. 
Dog-bite. See Saliva. 
Duboisia (probably identical 
with Hyoscyamus). 
Elaterium (Elaterin) 
Purging, vomiting, salivation, prostration, 
clonic spasms; dyspnea. 
Emetics; stomach-pump; 
demulcent drinks; opium. 
Ergot 
Tingling in the fingers and feet, cramps in 
the extremities, dizziness, weakness, 
pupils dilated, pulse small, vomiting, 
retching, and diarrhea. 
Evacuate, quick purgatives, 
castor-oil or Epsom salts; 
tannic or gallic acid; re- 
cumbent position; stimu- 
lants; amyl nitrite. 
Erythroxylon coca. See Coca 
in. 
Eserin. See Physostigma. 
Ether 
Sense of strangulation; cough, stage of ex- 
citement (cerebral intoxication). Tetanic 
convulsive stage, complete insensibility, 
muscles relaxed, reflexes abolished, cere- 
bral functions suspended. 
Paralysis of respira- 
tion. 
Withdraw vapor; lower the 
head; draw tongue for- 
ward ; atropin; artificial 
respiration; amyl nitrite; 
ammonia; warmth. 
Ethidene Dichlorid 
Stertorous breathing, dilated pupil, pleas- 
ant dreams, depression of pulse. 
Remove vapor; draw tongue 
forward; artificial respira- 
tion; lower the head. 
Ethyl Bromid 
Very similar to those of Chloroform, q. v. 
Euphorbia officinarum (Eu- 
phorbia Spurge). 
Pain; nausea; vomiting; purging; weak 
pulse. 
Paralysis of cardiac 
and respiratory 
centers. 
Evacuate; heart-stimulants. 
Eqalgin 
Numbness and tingling, cyanosis, salivation, 
vomiting, intense dyspnea feeling 
of alternate expansion and contraction of 
the head. 
Paralysis of respira- 
tion. 
Emetics; strychnin; stimu- 
lants. 
Filix mas (Male Fern). See 
Aspidium. 
Fish, Poisonous. (Several 
kinds of fish, particularly 
shell-fish, are constantly 
poisonous, while some are so 
only to particular constitu- 
tions.) 
Nausea, vomiting, irritation of eyes, de- 
pression, severe urticaria, or nettle-rash. 
Evacuate; quick purgative; 
stimulants. 
Fish-berries. See Cocculus. 
Fly, Spanish. See Cantharis. 
Foxglove. See Digitalis. 
Fungi. (Several forms of 
fungi, known as mushrooms, 
toadstools, truffles, etc., are 
directly poisonous.) 
Gastrointestinal catarrh, nausea, heat and 
pain, vomiting and purging, fainting, con- 
vulsions, small and frequent pulse; pupils 
dilated; delirium, stupor, death. 
Evacuate; quick purgative; 
Glauber's or Epsom salts; 
stimulants. 
Fusel-oil 
Rigidity of muscles, respiration shallow 
and slow, pupils small, odor of breath 
resembling amyl nitrite. 
Evacuate; heart stimulants. 
Gamboge 
Violent irritation of alimentary canal; 
vomiting; griping. 
Evacuate; demulcentdrinks; 
opium. 
Gaultheria procumbens 
(Wintergreen). 
Very similar in action to Acid, Salicylic, 
q. v. 
Gelsemium sempervirens (Yel- 
low Jessamin). 
Symptoms appear in about 20 minutes; 
great muscular weakness; dimness of 
vision, ptosis, diplopia, labored respira- 
tion, weak pulse. 
Paralysis of the re- 
spiratory centers. 
Evacuate; atropin; stimu- 
lants; artificial respiration; 
hot and cold douches. POISONS 
POISONS 
POISONS, TABLE OF. 
Name. 
Symptoms of Poisoning. 
Mode of 
Producing Death. 
Treatment and Antidotes. 
Glass 
Purely irritant; may have hematemesis... 
Bread in crumbs, then 
emetic. 
Gold 
Causes a pink stain upon the skin 
Sulphate of iron; albumin; 
evacuate. 
Gratiolus officinalis {Hedge- 
hyssop) . 
Violent purging; pain 
Evacuate; demulcent drinks 
Hedeoma {Pennyroyal) 
Unconsciousness, extremities cold, pulse 
small, pupils slightly dilated, vomiting, 
delirium, opisthotonos. 
Evacuate. 
Hellebore, Green and White. 
See Veratrum. 
Helleborus niger {Black Helle- 
bore) . 
Resemble malignant cholera; abdominal 
pain, vomiting, purging, vertigo, cold 
sweats, and collapse. 
Paralysis of heart.. 
Stomach-pump; tannin; mu- 
cilaginous drinks; heart- 
stimulants. 
Hemlock. See Conium. 
Henbane. See Hyoscyamiis. 
Holly Berries {Ilex aquifo- 
lium). 
Vomiting, pain in the head and abdomen, 
purging, contraction of pupils, loss of con- 
sciousness, collapse. 
Evacuate; stimulants; 
warmth; coffee. 
Homa tropin. See Atropa. 
Hura crepitans {Sand-box).... 
Irritation of alimentary tract; vomiting; 
purging. 
Evacuate.; demulcent drinks; 
opium. 
Hydrophobia. See Saliva. 
Hyoscyamus albus {White 
Henbane). 
Hyoscyamus niger {Black 
Henbane). 
Hyoscyamin, 
Hyoscin. 
Giddiness, sense of weight in head, general 
loss of power, pupils dilated, diplopia, 
presbyopia, flashes of light, incoherence 
of speech, delirium, insensibility, coma. 
Paralyzes respira- 
tion. 
Evacuate; quick purga- 
tives. 
Insects, Poisonous. (The bite 
or sting of several varieties of 
insects is poisonous.) 
In most cases slight; in cases of tarantula 
and scorpion may be more serious; pain, 
swelling, fever, erysipelas, suppuration, 
and gangrene, with death. 
In milder cases ammonia, 
soap, or other alkali to the 
wound. In graver cases 
similar to that of snake- 
bite, q. v. 
lodin and its compounds..... 
Pain in throat and stomach; vomiting, 
purging; vomit yellow from iodin, or blue 
if starch be present in the stomach; giddi- 
ness, faintness, convulsive movements. 
Paralysis of the 
heart. 
Evacuate; starch; amyl ni- 
trite; morphin. 
Iodoform 
Slight delirium; drowsiness; high tempera- 
ture, rapid pulse; resembles meningitis. 
Ipecacuanha {Ipecacuanha)... 
Vomiting, hematemesis, and hemoptysis.. 
Evacuate. 
Iron and its compounds 
Metallic taste, pain, vomiting, and purging; 
vomited matter black. 
Magnesia and diluents; ice 
and opium. 
Jaborandi. 
Pilocarpin. 
Copious sweating, dizziness, salivation, 
vomiting, diarrhea, tearing pain in eye- 
balls, myopia, pupils much contracted. 
Evacuate; stimulants; atro- 
pin or belladonna. 
Jalap 
Copious watery stools, tormina, and tenes- 
mus. 
Evacuate; demulcent drinks. 
Jamaica Dogwood. See Pis- 
cidia. 
Jatropha curcas {Indian Nut) 
Purging; vomiting 
Evacuate; demulcent drinks. 
Jatropha manihot {Cassava).. 
Same as those of Prussic Acid, q. v. 
Juniperus sabina. See Savin. 
Juniperus virginiana {Red 
Cedar). 
Gastritis; nephritis; strangury; nervous 
disturbances; violet-like odor in urine; 
copaiba-like erythema. 
Evacuate; demulcent drinks; 
stimulants. POISONS 
POISONS 
POISONS, TABLE OF. 
Name. 
Symptoms of Poisoning. 
Mode of 
Producing Death. 
Treatment and Antidotes. 
Lactic Acid. See Acid, Lactic. 
Lactuca virosa (.Strong-scented 
Lettuce). 
Somewhat similar to those of Opium, q. v. 
Laudanum. See Opium. 
Lead and its compounds 
Dryness of the throat, metallic taste, great 
thirst, colic relieved by pressure, abdom- 
inal muscles usually rigid, constipation, 
cramps in the legs, paralysis of the ex- 
tremities, convulsions; in the chronic 
forms, a blue line at margin of the gums. 
Evacuate; dilute sulphuric 
acid; Epsom and Glauber's 
salts; milk; morphin; iodid 
of potassium to eliminate 
the poison; poultices to the 
abdomen. 
Lime 
Burning pain in the abdomen, great thirst, 
obstinate constipation. 
Vegetable acids; demulcent 
drinks. 
Lobelia inflata (Indian To- 
bacco) . 
Severe vomiting, with intense depression 
and prostration, giddiness, tremors, con- 
vulsions, collapse. 
Paralysis of respira- 
tion. 
Evacuate stomach; tannic 
or gallic acid; stimulants; 
strychnin; warmth; re- 
cumbent position. 
Lolium temulentum (Darnel). 
Vertigo; dizziness; headache; sleepiness. 
Lytta vittata (Potato-fly) 
Similar to those of Cantharis, q. v. 
Male fern. See Aspidium. 
Meat. (Putrefactive changes 
in meat and some other forms 
of food produce active poi- 
sonous agents known as 
ptomains. 
Gastrointestinal irritation sometimes very 
marked; occasionally death. 
Evacuate; irrigate stomach; 
sedatives; supportive treat- 
ment when prostration. 
Melia azedarach (Pride of 
China). 
Giddiness, dimness of vision, stertorous 
breathing, dilated pupils, stupor. 
Mercury and its compounds. . 
Acrid metallic taste, burning heat in throat 
and stomach, vomiting, diarrhea, with 
bloody stools, lips and tongue white and 
shriveled, pulse small and frequent, death 
in coma or convulsions; pain may be ab- 
sent Secondary symptoms: hectic fever, 
coppery taste, fetid breath, gums swollen, 
salivation. 
Albumin in some form; raw 
white of egg or flour; 
evacuate; potassium iodid; 
opium. 
Methylene Bichlorid 
Symptoms and treatment similar to those 
of Chloroform, q. v. 
Mezereon 
Violent purging, vomiting, nephritis, and 
gastroenteritis; an exceedingly powerful 
local irritant. 
Evacuate; aperient and de- 
mulcent drinks; opium. 
Milk. See Tyrotoxicon. 
- .. , 
Momordica elaterium (Squirt- 
ing Cucumber). 
Morphin. See Opium. 
Mushrooms. See Fungi. 
Mussel. See Fish. 
Mydalin. See Meat. 
Myristica fragrans (Nutmeg).. 
Thirst; tightness in the chest; vomiting... 
Coffee and stimulants. 
Mytilotoxin (Mussel-poison). 
See Fish. 
Naphthalin 
Cyanosis, twitching over body, urine 
dark-brown changing to inky black, 
strangury. 
Demulcent drinks; stimu- 
lants. 
Narcein. See Opium. 
Narcissus pseudonarcissus 
(Daffodil). 
Evacuate; demulcent drinks; 
stimulants. POISONS 
POISONS 
POISONS, TABLE OF. 
Name. 
Symptoms of Poisoning. 
1 
Mode of 
Producing Death. 
Treatment and Antidotes 
Nerium oleander (Oleander').. 
Similar to those of Strophanthus, q. v. 
Neurin. See Meat. 
Nicotiana tabacum. See Tob 
acco. 
Nightshade. See Atropa. 
Niter (Potassium Nitrate). See 
also Potassium and its com- 
pounds. 
Pain in the abdomen, vomiting, coldness in 
the limbs, partial paralysis, tremors, con- 
vulsions, collapse. 
Paralysis of the 
heart. 
Evacuate; mucilaginous 
drinks; stimulants; warm th; 
amyl nitrite; atropin. 
Nitric Acid. See Acid, Nitric 
Nitrobenzin 
Nitrobenzol. 
May be delayed; weariness, numbness in 
the head, confusion, marked cyanosis, 
lips nearly black, convulsions, pupils 
dilated. 
Asphyxia 
Cold to head; dilute am- 
monia; hydrated oxid of 
iron; stimulants; artificial 
respiration. 
Nitroglycerin 
Throbbing headache; pulsation over en- 
tire body, dicrotic pulse, flushed face, 
mental confusion, anxiety, sudden col- 
lapse. 
Respiratory paral- 
ysis. 
Recumbent position; cold to 
head; ergot; atropin. 
Nitrohydrochloric Acid. 
See Acid, Nitrohydrochloric. 
Nitrous Oxid 
Respiratory paral- 
ysis. 
Pull tongue forward; air; 
artificial respiration; 
douche; oxygen. 
Nux vomica. See St. Ignatius' 
Bean. 
Opium 
Morphin. 
Narcein. 
Codein. 
Laudanum. 
Preliminary mental excitement, accelera- 
tion of heart; soon headache, weariness, 
sensation of weight in the limbs, sleepin ess, 
diminished sensibility, contracted pupils; 
pulse and respirations slow and strong; 
patient can be roused with difficulty; 
later this becomes impossible; reflexes 
abolished, jaw falls; respiration slow, 
irregular, and stertorous; pulse rapid and 
feeble. 
Respiratory paral- 
ysis. 
Evacuate stomach; apo- 
morphin; rousing; am- 
monia; coffee; douche; 
atropin; amyl nitrite; 
artificial respiration; exter- 
nal heat; battery; strych- 
nin; potassium permanga- 
nate; oxygen. 
Oxalic Acid. See Acid, Oxalic. 
Papa ver somniferum (Poppy). 
See Opium. 
Paraldehyd 
Similar to chloroform-narcosis 
Paralysis of respir- 
atory center. 
Respiratory stimulants; cof- 
fee; atropin; battery. 
Paris Green. See Arsenic. 
Peach-kernel-contains Acid, 
Hydrocyanic, q. v. 
• 
Petroleum 
Burning in course of alimentary tract; 
excreta covered with layer of oil; skin 
cold; pulse feeble, but regular; respiration 
sighing; thirst; restlessness. 
Evacuate; stimulants; 
warmth; stimulation of 
skin; artificial respiration. 
Phenacetin (acetphenetidin).. 
Very similar to Antipyrin and Antijebrin, 
q. v. 
Phenol. See Acid, Carbolic. 
Phosphorus 
Vomiting and pain; vomit may be lumin- 
ous in the dark; characteristic odor; after 
several days deep jaundice, coffee colored 
vomit, hepatic tenderness, failure in pulse 
and respiration; coma or delirium; albu- 
min in the urine. 
Failure of respira- 
tion and circula- 
tion. 
Sulphate of zinc or copper; 
Epsom salts; never give oi 
or fat. 
Physostigma venenosum 
(Calabar Bean). 
Eserin. 
Giddiness; prostration; loss of power in 
the lower limbs; muscular twitching; con- 
tracted pupils; mind clear. 
Asphyxia 
Evacuate; atropin; strych- 
nin; stimulants; artificial 
respiration. POISONS 
POISONS 
POISONS, TABLE OF. 
Name. 
Symptoms of Poisoning. 
Mode of 
Producing Death. 
Treatment and Antidotes. 
Phytolacca decandra (Poke).. 
Nausea; vomiting; depression; heart, as 
well as respiration, slowed; tetanic con- 
vulsions. 
Paralysis of respir- 
ation. 
Evacuate; alcohol; opium; 
ether; digitalis. 
Picrotoxin. See Cocculus. 
Pilocarpin. See Jaborandi. 
Pinkroot. See Spigelia. 
Piper cubeba. See Cubeb. 
Piscidia erythrin (Jamaica 
Dogwood). 
Muscular relaxation; accelerated pulse; 
lowered sensibility; dilated pupils; deep 
sleep. 
Asphyxia 
Same as for Opium, q. v. 
Pituri 
Slightly narcotic; powerful respiratory poi- 
son. 
Similar to Atropin, q v. 
Plumbago europa (Toothwort). 
Violent emesis 
Evacuate; demulcent 
drinks; heart-stimulants. 
Poison-oak. 1 ~ 
Poison-vine. ) See 22Aus. 
Poke-berries. See Phytolacca. 
Poppy. See Opium. 
Potassium and its compounds. 
The hydrate produces the symptoms of 
other caustic alkalies, e. g., lime; the 
other poisonous compounds are to be 
classed under their various acids. 
For caustic potash. Vege- 
table acids; demulcent 
drinks. 
Potato-fly (Dytta vittata). See 
Cantharis. 
Privet (Ligustrum vulgare) ... 
Purging; intestinal inflammation 
Hot water in large draughts; 
warmth; stimulants. 
Prunus laurocerasus (Cherry 
Laurel). 
Prunus virginiana (Wild 
Cherry). 
Both contain Acid, Hydrocyanic, q. v. 
Prussic Acid. See Acid, Hydr 
o cyanic. 
Ptomains. See Meat. 
Pulsatilla 
Lowers heart's action, reduces respiration 
and temperature; dilates pupils; para- 
lyzes motion and sensibility. 
Paralysis of heart.. 
Alcohol; opium; digitalis. 
Pyrogallic Acid. See Acid, 
Pyrogallic. , 
Resorcin ■ 
Giddiness, tingling; insensibility, profuse 
perspiration; tongue dry; pupils normal; 
teeth clenched, temperature low; urine 
black. 
Paralysis of respir- 
ation. 
Evacuate; albumin; stim- 
ulants; warmth; atropin; 
amyl nitrite; red wine. 
Rhus radicans (Poison-vine).. 
Rhus toxicodendron (Poison- 
oak). 
Cutaneous irritation; itching, swelling, 
vesicular eruption; may involve the 
throat, producing cough; thirst, vomit- 
ing, colicky pains, fever, delirium. 
Grindelia robusta locally; 
also carron-oil and solu- 
tion of acetate of lead; also 
phenol 5 percent, solution 
or cocain 5 percent, solu- 
tion or ichthyol; rest; low 
diet; laxatives; opium. 
Ricinus communis (Castor- 
oil). 
Burning, nausea, vomiting, colicky pains, 
small pulse, great prostration; purging 
may or may not occur. 
Evacuate; morphin, hypo- 
dermatically; warmth; 
stimulants; starch and 
opium enemata. 
Rue 
Ruta graveolens (Rue). 
Violent gastroenteritis, extreme prostra- 
tion, convulsions, strangury, suppression 
of urine. 
Evacuate; demulcent 
drinks; diuretics; heart 
stimulants. 
Salicylic Acid. See Acid, 
Salicylic. POISONS 
POISONS 
POISONS, TABLE OF. 
Name. 
Symptoms of Poisoning. 
Mode of 
Producing Death. 
Treatment and Antidotes. 
Saliva of Rabid Animals 
Rarely come on in less than three weeks; 
may occur between that and years; pain 
in the bitten part; uneasiness, languor, 
difficult respiration, difficulty in swallow- 
ing, horror of water; violent convulsions; 
tongue swollen and often protruding; 
flow of viscid saliva. 
Preventive: 
Immediate ligature above 
wound; excision; cautery; 
inoculation. 
Of hydrophobia: 
Chloroform internally; 
morphin hypodermatical- 
ly; cocain to throat; 
nutritive enemata. 
Sambucus canadensis (Elder). 
Emesis; purging 
Demulcent drinks; evacuate. 
Sanguinaria canadensis 
(Bloodroot). 
Salivation, catharsis, and vomiting, reflex- 
es lowered; pupils dilated; temperature 
low; great thirst; collapse. 
Paralysis of the 
cardiac and respi- 
ratory centers. 
Evacuate; opium; amyl ni- 
trite; atropin. 
Santonin 
Disturbance of color-vision-objects first 
assume a bluish tinge, then yellow; tin- 
nitus; dizziness; pain in the abdomen; 
failure of respiration; convulsions; stupor. 
Asphyxia 
Evacuate; stimulants; chlo- 
ral. 
Savin 
Pain, vomiting, tenesmus, and bloody 
stools; disordered respirations; coma, and 
convulsions. 
Evacuate stomach; castor- 
oil in large dose; morphin: 
poultices to the abdomen. 
Scammony 
Vomiting, purging, griping, tenesmus 
Evacuate; stimulants. 
Scilla maritima (Squill) 
Vomiting, purging, strangury, bloody 
urine, paralysis, and convulsions. 
Paralysis of heart 
in systole. 
Evacuate; demulcent drinks; 
diuretics; stimulants. 
Secale cornutum. See Ergot. 
Silver and its salts 
Pain, vomiting, and purging; vomit white 
and cheesy, rapidly turning black in the 
sunlight; vertigo, coma, convulsions, 
paralysis, and marked disturbance of 
respiration. 
Paralysis of respir- 
ation. 
Salt and water; evacuate 
stomach; a large amount 
of milk; albumin. 
Snake-bite. (The bite of many 
varieties of serpents is di- 
rectly poisonous.) 
Vary in severity, but are, in the main, 
sharp pain in the bitten part, rapidly 
spreading; great swelling of the wounded 
member, which becomes livid and gan- 
grenous later; fainting, vomiting, and 
convulsions; pulse small, frequent, and 
irregular; breathing difficult. 
Paralysis of cardiac 
and respiratory 
centers. 
Removal of poison by suck- 
ing or cupping; ligature 
above wound; cautery or ex- 
cision; ammonia to wound 
and internally; warmth; in 
some cases large doses of 
ammonia or whisky inter- 
nally; transfusion of blood. 
Soda (Sodium) 
Symptoms and treatment similar to those 
of other caustic alkalies, as Lime, q. v. 
Solanum dulcamara (Bitter- 
sweet) . 
Thirst, headache, giddiness, dimness of 
vision, dilated pupils, convulsions, vomit- 
ing, purging. 
Asphyxia 
Evacuate; stimulants; 
warmth. 
Sorbus acuparia (Mountain 
Ash). 
Same as for Opium, q. v. 
Spanish Fly. See Cantharis. 
Spigelia marilandica (Pink- 
root) . 
Vertigo, dimness of vision, dilated pupils, 
spasms, convulsions; delirium; dryness of 
throat. 
Evacuate; stimulants; cof- 
fee. 
Squill. See Scilla. 
Stalagmitis cambogioldes. See 
Gamboge. 
Staphisagria 
Heart slow and feeble; breathing difficult; 
pupils dilated; abdomen distended and 
painful. 
Paralysis of spinal 
cord and asphyxia. 
Cardiac and respiratory 
stimulants. 
Stavesacre. See Staphisagria. 
Stramonium. See Datura. 
Strophan thus (Arrow-poison). 
Strophan thin. 
Weakness of pulse; increase of urine, rigid- 
ity of the muscles; spasms. 
Paralysis of the 
heart in systole. 
Cardiac stimulants. POISONS 
POISONS 
POISONS, TABLE OF. 
Name. 
Symptoms of Poisoning. 
Mode of 
Producing Death. 
Treatment and Antidotes. 
St. Ignatius Bean 
Strychnos ignatia. 
Strychnos nux vomica (Nux 
vomica). 
Nux vomica. 
Strychnin. 
Brucin. 
Tetanic convulsions coming on in parox- 
ysms at varying intervals of from five 
minutes to half an hour; opisthotonos 
during paroxysm; eyeballs prominent; 
pupils dilated, respiration impeded, 
pulse feeble and rapid; anxiety. 
Asphyxia during 
paroxysm, or col- 
lapse. 
Evacuate stomach; tannic 
acid ad fib.; follow with 
emetic; catheterize; keep 
patient quiet; bromids and 
chloral; amyl nitrite or 
chloroform, to control con- 
vulsions; artificial respira- 
tion if indicated. 
Sulphonal 
Giddiness, weakness, ptosis, cyanosis, 
suppression of urine. 
Stimulants; diuretics. 
Sulphuric Acid. See Acid, Su 
Iphwric. 
Sumach. See Rhus. 
Tanacetum vulgare (Tansy).. 
Tansy. 
Convulsions, insensibility, dilated pupils, 
respirations hurried and stertorous; pulse 
full, gradually failing; characteristic odor 
of breath. 
Heart-paralysis.... 
Heart-stimulants; evacuate. 
Tartar Emetic. See Anti 
mony. 
Tartaric Acid. See Acid, Tar 
taric. 
Tin 
Metallic taste, vomiting, and diarrhea; 
pain; depressed action of heart. 
- ■ 
Evacuate; magnesium; mu- 
cilaginous drinks. 
Tobacco 
Nicotin. 
Nausea, vomiting, weakness, weak pulse, 
cold and clammy skin, collapse, pupils 
contracted, then dilated. 
Paralysis of respira- 
tion ; sometimes 
paralysis of heart. 
Evacuate stomach; tannic 
acid; strychnin; stimu- 
lants; warmth; recumbent 
position. 
Truffles. See Fungi. 
Turpentine 
Characteristic odor; intoxication; con- 
tracted pupils; stertorous breathing; 
coma; collapse; tetanic convulsions; the 
urine has the odor of violets. 
Paralysis of respir- 
ation. 
Evacuate; magnesium sul- 
phate; demulcent drinks; 
morphin. 
Tyrotoxicon 
Nausea, vomiting, cramps, diarrhea, col- 
lapse. 
Evacuate; intestinal anti- 
septics. 
Urethan 
Vomiting; slowing of heart; temperature 
lowered; muscular resolution and general 
anesthesia. 
Asphyxia 
Evacuate; cardiac stimu- 
lants. 
Vaselin 
Cramps in lower limbs, severe and persist- 
ent vomiting; collapse. 
Evacuate; stimulants. 
Veratrum album (White Helle- 
bore) . 
Veratrum viride (Green Helle- 
bore). 
Burning and pain in course of alimentary 
tract; inability to swallow; vomiting and 
( diarrhea; palpitation; slow, weak pulse; 
respiration labored; pupils generally 
i dilated; may be convulsions. 
Paralysis of respir- 
atory centers. 
Evacuate stomach; ether 
hypodermatically; opium; 
stimulants; coffee; warmth; 
recumbent position. 
Verdigris. See Copper. 
Wild Cherry. See Prunus. 
Wintergreen. See Gaultheria. 
Woorara. See Curare. 
Yew 
j Vomiting and delirium; pain in abdomen; 
: irregularity of the heart's action; death 
. may be sudden. 
Evacuate; quick purgation; 
stimulants. 
Zea mays (Maize) 
Slow heart; dilated pupils; tonic convul- 
sions. 
Tetanus of respira- 
tory muscles, or 
exhaustion. 
Cardiac and respiratory 
stimulants. 
Zinc. 
Corrosion of lips or mouth; pain and burn- 
ing; incessant vomiting, the vomit blood- 
1 stained; acceleration of pulse and respira- 
tion; dyspnea; dilatation of the pupils; 
epileptiform convulsions; paralysis; coma. 
Sodium or potassium car- 
bonate; milk; eggs; tannic 
or gallic acid; morphin 
hypodermatically; p o u 1- 
tices to abdomen. POISONING, MEDICOLEGAL 
POISONING, MEDICOLEGAL 
Household Antidotes.-When the other articles 
to be used as antidotes are not in the house, give 
2 tablespoonfuls of prepared mustard in a pint of 
warm water. Also give large drafts of warm milk, 
or water mixed with oil, butter, or lard. 
between the clinical, anatomic, and chemic evidence 
is a most serious obstacle to a decisive result in 
court, and witnesses for the prosecution are some- 
times singularly blind to very obvious defects of 
this kind in State evidence. The scientific value 
of medical opinion in poisoning cases has been 
considerably overrated in the past, and when its 
limitations have become more clearly recognized 
on all sides, the present undignified conflict of 
scientific opinion in court will probably become a 
thing of the past. Overpositiveness is the root of 
nearly all evil in medical testimony. 
In any medicolegal autopsies with negative 
results, poisoning should be borne in mind, and 
the necessary materials preserved until the case 
is cleared up, in case an analysis may be necessary. 
Finding of an immediate cause of death of another 
nature does not always exclude poisoning. For 
instance, a man may be drugged previous to a 
fatal assault, or the death of a sick person hastened 
by poison. 
In making a report, after fully stating all facts 
established by the autopsy, but without introduc- 
ing extraneous circumstances, the conclusions 
should be concisely drawn up. These should be 
limited to what is proved by the report beyond 
contradiction, and may usually be expressed in 
one or other of the following formulas: 
1. The autopsy does not show cause of death. 
To determine whether poisoning has occurred, an 
analysis will be necessary. 
2. Conditions found are characteristic of poison- 
ing by 
3. Conditions found are consistent with poisoning 
by (or are not consistent). 
4. Death is due to. . . (natural cause), poison- 
ing by is excluded (or 
not excluded, or not demonstrated). 
Preliminaries.-The following general precau- 
tions are to be observed: The autopsy should be 
done by two medical men, with some one to take 
notes. Persons suspected must not be present at 
the autopsy, but may be represented. The iden- 
tity of the body should be carefully established. 
In exhumations the pathologist should be present 
when the coffin is opened, and samples of soil 
above and below the coffin should be taken. Lin- 
ings or shavings within the coffin, if soaked with 
fluid from body, should be preserved. Provide a 
sufficient number of clean new glass jars (the "gem" 
jar pattern will answer)-at least a dozen should 
be available. Materials for analysis should be 
kept under personal supervision and delivered by 
hand to the chemist-not sent by mail or express. 
Provide facilities for examining the organs with- 
out contact with substances which would inter- 
fere with chemic analysis. If new and clean porce- 
lain dishes are not available, pieces of freshly 
sawed boards will answer. Decomposition is best 
prevented by freezing the organs. If available, 
a cold-storage chamber is best. When absolutely 
necessary to prevent decomposition, pure alcohol 
is recommended, a control sample being reserved 
for analysis (probably formalin will prove a bet- 
ter preservative, but its possible influence on the 
results of analysis is not yet known). A sample 
For bed-bug poison, 
For corrosive sublimate, 
For blue vitriol, 
For lead-water, 
For saltpeter, 
For sugar of lead, 
For sulphate of zinc, 
For red precipitate, 
For vermilion, 
Give milk or white of eggs, 
large quantities. 
For Fowler's solution, 
For white precipitate, 
For arsenic, 
Give prompt emetic of mus- 
tard and salt, tablespoonful of 
each; follow with sweet oil, 
butter, or milk. 
For antimonial wine, 
For tartar emetic, 
Drink warm water to encour- 
age vomiting. If vomiting 
does not stop, give a grain of 
opium in water. 
For oil of vitriol, 
For aquafortis, 
For bicarbonate of potas- 
sium, 
For muriatic acid. 
For oxalic acid, 
Magnesia or soap dissolved in 
water, every 2 minutes. 
For caustic soda, 
For caustic potash, 
For volatile alkali, 
Drink freely of water with 
vinegar or lemon-juice in it. 
For carbolic acid, 
Give flour and water, glutinous 
drinks, and a form of alcohol. 
For chloral hydrate, 
For chloroform, 
Pour cold water over the head 
and face, with artificial res- 
piration, galvanic battery. 
For carbonate of sodium, 
For copperas, 
For cobalt. 
Prompt emetics; soap or muci- 
laginous drinks. 
For laudanum, 
For morphin, 
For opium, 
Strong coffee followed by 
ground mustard or grease in 
warm water to produce 
vomiting. Keep in motion. 
For nitrate of silver, Give common salt in water. 
For strychnin, 
For tincture of nux vomica, 
For iodin and iodids, 
Emetic of mustard or sulphate 
of zinc, aided by warm water. 
Prompt emetic; solution of 
starch; flour and water. 
POISONING, MEDICOLEGAL DUTIES IN 
FATAL CASES.-The duties of the medical ex- 
aminer are: 
1. To establish the presence or absence of condi- 
tions characteristic of any poison. 
2. To preserve all necessary material for analy- 
sis, taking care that nothing thereby is done to 
introduce causes of error. 
3. To recognize or exclude natural causes of 
death. 
4. If necessary, to perform experiments upon 
animals to demonstrate the toxic effect of sub- 
stances separated by the chemist. 
5. To record carefully all personal observations 
and to state clearly the conclusions as to the cause 
of death. 
Information as to the circumstances of the 
death, while guiding the medical examiner in his 
mode of proceeding, must not bias his scientific 
opinion. 
The most difficult cases are those in which the 
postmortem appearances are negative or consist- 
ent either with disease or poison. In these, how- 
ever, the postmortem evidence, though necessary, 
is only of indirect value. Want of harmony POISONING, MEDICOLEGAL 
POISONING, MEDICOLEGAL 
of the jar used should be kept. The jars are to be 
sealed by attaching tape to both jar and cover by 
means of sealing-wax, the seal being retained. 
Jars containing decomposing tissues should be 
loosely stoppered to prevent bursting. A signed 
and dated label should be placed on each jar. By 
knowing the tare weight of the jars, or by using a 
counterpoise, organs may be weighed while in the 
jars. 
The autopsy should be made as soon after death 
as possible, but preferably not by artificial light. 
The modern undertaker's fondness for embalming 
bodies is a serious inconvenience, but, fortunately, 
the arsenical preparations are being superseded by 
formalin. In some States legislative restrictions 
specifically forbid the embalming of bodies pend- 
ing judicial inquiry. 
Poisons introduced after death may diffuse 
through the tissues and enter remote organs, 
though most concentrated at point of insertion. 
The compounds formed by rapid putrefaction at 
high temperatures are less likely to be confused 
with alkaloidal poisons than those slowly formed 
at low temperature. 
When practicable, the chemist may, with ad- 
vantage, be present at the autopsy, but unless he 
is personally accustomed to postmortem work, 
the results of this assistance may be disappointing. 
Want of familiarity with ordinary cadaveric odors 
interferes much with the recognition of those char- 
acteristics of volatile poisons. On the other hand, 
the pathologist should be present at the opening 
and examination of the stomach and intestines if 
this is done by the chemist. 
Technic. External Examination.-The sur- 
roundings of the body may give important infor- 
mation. Any substances which might contain 
poison found in the vicinity should be seized and 
preserved; the surface of the body should be exam- 
ined for traces of corrosion or evidences of poison 
spilt. The mouth, lips, and tongue need careful 
examination, and the whole surface should be 
examined for hypodermic punctures. At all 
stages of the autopsy characteristic odors should 
be watched for. These may be masked by the 
odor from intestines, and hence may be best 
detected in the brain before the other cavities are 
opened. In a well-equipped laboratory facilities 
for making preliminary tests should be at hand. 
Internal Examination.-Authorities differ as to 
the best order for examination of the organs. In 
Germany official regulations insist on the ligation 
and removal of the stomach and duodenum as the 
first step in the autopsy, to be done before opening 
the thorax. This has the advantage of interrupt- 
ing the continuity between esophagus and stomach. 
French authorities insist strongly on the preserva- 
tion of the blood for analysis of the dissolved gases, 
also on the separate preservation of the urinary 
organs, as in these alkaloids are found in the 
greatest state of purity. American toxicologists 
lay stress-and that rightly-upon large quanti- 
ties of the tissues being preserved, and, especially 
in chronic poisoning, of analysis of large quanti- 
ties of muscle and bone. Witthaus advises pre- 
serving, in separate jars, (1) the stomach and duo- 
denum and contents, ligated and unopened; (2) 
the rest of the intestine and contents, ligated and 
unopened; (3) the entire liver; (4) the blood from 
the heart and vessels; (5) both kidneys; (6) the 
urine; (7) the entire brain; (8) a large piece of mus- 
cle from the thigh; portions of the bones and spleen 
may also be taken with advantage. Fairly satis- 
factory analyses, however, may be made with 
amounts considerably less. If only a few jars are 
available, group together (1) stomach and intes- 
tine with contents; (2) liver; (3) brain, blood, 
spleen, and kidneys, etc.; (4) bone or muscle. 
When the autopsy is done under very unfavorable 
surroundings, it may be safer simply to eviscerate 
all the organs, placing them in a large enamel ves- 
sel for immediate transport to the laboratory. 
Proof of poisoning has been established by 
chemists by analysis of muscles or one kidney, 
when all the other tissues have been removed and 
got rid of by the suspected parties. 
Important information as to the time of absorp- 
tion is shown by the distribution of poisons in the 
various tissues. The unabsorbed residue is found 
in the stomach and intestines, plus whatever may 
have been excreted by the intestines. Poisons 
in both stomach and liver indicate a short interval 
between the taking and the death. Poison in the 
liver and organs, with none in the stomach, indi- 
cates a greater interval if the poison was taken by 
mouth. Most poisons remain in the liver after 
disappearance from the stomach, and remain 
longer in the muscles and bones than in any other 
tissue. Poisons are found in their greatest purity 
in the kidneys and urine. When chronic poison- 
ing is suspected during life, a sample of urine may 
be quietly secured for analysis without arousing 
suspicion. Apart from the analysis, the stomach 
contents give valuable information as to the time 
and composition of the last meal, which may have 
a very important and circumstantial bearing. 
In corrosive poisoning, the best results are 
obtained by removing the mouth, esophagus, 
stomach, and duodenum together. The fauces 
and pharynx, besides corrosion, may show foreign 
substances, and any particle between the teeth 
should be carefully examined. The crucial point 
of the autopsy is the opening and examination of 
the stomach, which should be done over a vessel 
suitable for receiving the contents, the mucous 
membrane being spread out and examined with a 
hand lens for lesions and suspicious substances. 
The cooperation and presence of the chemist at 
this stage is specially valuable, but the examina- 
tion of the stomach by the chemist alone may lead 
to statements very extraordinary from a patho- 
logic point of view. 
For analysis of contained gases in blood, the 
bottles should be completely filled and tightly 
stoppered. 
It must be remembered that besides the exam- 
ination for poisons and their lesions, every organ 
must be thoroughly examined and all natural 
causes of death, in particular the causes of sud- 
den death, rigidly excluded. Particular attention 
must be paid, therefore, to the cerebral, pulmo- 
nary, and coronary arteries, the veins and other POISONING, MEDICOLEGAL 
POISONING, MEDICOLEGAL 
sources of embolism, the heart-muscle, brain, and 
the air-passages. 
In addition no examination should be neglected 
which will forestall subsequent hypothetic ob- 
jections, the spinal cord being best examined as 
part of the routine. It is most necessary that 
microscopic and bacteriologic studies be made 
when these will yield any information. Small bits 
of tissue preserved in formalin for microscopic 
examination will often give decisive information 
in organs too decomposed to be trustworthy to the 
naked eye. 
Sources of Error.-The principal are: (1) Failure 
to recognize the existing appearances of poison- 
ing; (2) supposed detection of characteristic ap- 
pearances not really present; (3) misinterpreting, 
as effects of poison, lesions due to disease or to 
agonal or postmortem changes. In acute cases the 
possibility of remedial measures employed in 
modifying appearances must be borne in mind. 
The inflamed and reddened conditions of the 
stomach recorded for many poisons, are probably 
largely mistakes of observation. 
The stomach in full digestion is found intensely 
reddened postmortem. Softening of the mucosa 
after death may resemble erosion, and passive or 
hypostatic congestion may lead to suffusion of 
blood in the mucous membrane, with the ap- 
pearances strongly resembling those in inflam- 
mation. Due allowance must be made for the 
attitude of the mind when certain changes are 
expected. To pathologists, reddening or conges- 
tion of the stomach mucosa in itself indicates 
nothing important. 
Anatomic Distribution of Lesions.-The fol- 
lowing are some of the more common changes: 
Surface.-Pinkish lividity, from carbon monoxid 
or cyanid of potassium. 
Fauces, Esophagus, and Stomach.-Foreign sub- 
stances, corrosion effects, odors, inflammatory 
exudates, ulcers, and perforation; brittleness from 
acids; soapiness from alkalies. The microscopic 
examination of sloughs shows hemorrhagic in- 
filtration at the base, and may show crystals, as 
arsenic or oxalates. Diluted corrosives cause 
more inflammation, but less necrosis, than con- 
centrated ones. The stomach lesions lie mostly 
at the greater curvature and along the rugae. 
Among foreign substances, may be found match- 
heads, indicating phosphorus; cantharides scales, 
Paris-green particles, etc. Fatty change following 
cloudy swelling may occur secondarily in arsenic 
and phosphorus-poisoning. 
Intestines.-Diffuse pinkish congestion, with 
rice-water contents in arsenic poisoning, and mem- 
branous colitis in sublimate poisoning, are highly 
characteristic. 
Blood.-Carmin colored in poisoning by carbon 
monoxid and potassium cyanid; dark in prussic 
acid poisoning; chocolate brown, with destruction 
of red cells, from potassium chlorate and other re- 
ducing agents; dark, and free from clots in alcoholic 
or narcotic poisoning, and all conditions causing 
death by asphyxia. Distinctive odors may be 
present. 
Heart.-Fatty in subacute arsenic and phos- 
phorus-poisoning; ecchymoses of walls with phos- 
phorus-, and subendocardial ecchymoses with 
arsenic, poisoning. 
Lungs.-Congestion and bronchopneumonia 
from narcotics; carmin colored and edematous in 
carbon monoxid; fat emboli with phosphorus. 
Kidneys.-Cyanosed in alcoholism, with the hog- 
back shape; cloudy swelling and fatty change in 
arsenic and phosphorus; congestion and glomer- 
ular and papillary hemorrhages in cantharides; 
methemoglobin infarcts with potassium chlor- 
ate, etc. 
Liver.-Fatty with arsenic and phosphorus- 
jaundice in phosphorus. 
Lesions Characteristic of the More Important 
Poisons. Concentrated Sulphuric Acid.-Blacken- 
ing from carbonization in esophagus, stomach, and 
duodenum; perforation and charring of adjacent 
organs; erosion of skin. 
Dilute Sulphuric Acid.-Severe gastroenteritis, 
with sloughing and ulceration. 
Hydrochloric Acid.-Concentrated: corrosion, 
with gray color of the stomach; no corrosion of 
skin. Dilute: same as dilute sulphuric. 
Nitric Acid.-Intense yellow tint from the forma- 
tion of picric acid, tissues becoming very brittle. 
Caustic Alkalies.-Mucosa of mouth, esophagus, 
and stomach swollen, translucent, and brown, 
soapy to the touch, and with odor of lye. In later 
stages intense inflammation of stomach and esoph- 
agus (croupous in the case of ammonia), followed 
by ulceration. Stricture of esophagus frequently 
follows. 
Nitrous Acid Fumes.-Intense capillary bron- 
chitis, with edema of lungs. 
Corrosive Sublimate.-Severe gastroenteric with 
diphtheritic colitis and very marked cloudy 
swelling of the kidney. 
Arsenous Acid.-Intense congestion and hem- 
orrhage of stomach; diffuse pinkish congestion 
of small intestines, with rice-water contents, free 
from fetor. Subendocardial ecchymoses. In later 
stages, necrosis and fatty change in stomach, 
cloudy swelling and fatty change of kidneys, 
skin eruptions, and neuritis in chronic cases. 
Antimony Tartrate.-In acute cases general 
appearances similar to arsenic; in addition some- 
times pustular eruption where tissues are in con- 
tact with the solid particles, as in esophagus; 
greater tendency to engorgement of lungs with 
pulmonary apoplexy. 
Silver Nitrate.-Whitish coagulum, blackening 
on exposure to light; blackening of skin and in- 
ternal organs in chronic poisoning (very rare). 
Copper Salts.-Blue discoloration and tan ap- 
pearance of tissues. 
Lead.-In chronic cases blue line of gums, 
with fibrosis of the organs and nerves (changes 
not constant). 
Carbolic Acid.-Corrosion, with drying, harden- 
ing, and whitening of tissues; characteristic odor; 
stomach pinkish-gray; blood, in contact, brick- 
red; lungs engorged. 
Oxalic Acid.-Whitish coagulation of mucosa at 
point of contact; severe inflammation and hemor- 
rhage about corroded areas, if death is not im- POISONING, MEDICOLEGAL 
POLYCYTHEMIA 
mediate; infiltration of tissues by octahedral 
oxalate crystals. 
Phosphorus.-Sometimes luminosity of stomach 
contents; presence of match-heads, onion odor, 
intense jaundice, fatty degeneration of liver, 
kidneys, and heart; ecchymoses throughout entire 
body; fat embolism. In chronic forms necrosis 
of jaw. 
Carbon Monoxid.-Bright red lividity of surface. 
Carmin color of blood, with persistent fluidity 
and characteristic spectrum. Pinkish appearance 
of organ from alteration in blood tint. Edema 
of lungs; asphyctic state, with engorgement of 
organs. Delayed decomposition. Color of blood 
unaltered on adding alkalies, tannic acid, etc. 
Hydrocyanic Acid.-Asphyctic state; character- 
istic odor (masked in presence of ammoniacal 
decomposition). Blood becomes bright red on 
adding reducing agent. 
Cyanid of Potassium.-Asphyctic state; odor as 
in prussic acid; blood lake-colored. Mucosa of 
esophagus and stomach brownish-red, swollen, 
thrown into folds, translucent, and slippery. 
Nitrobenzol.-Intense cyanosis; odor of bitter 
almonds. 
Potassium Chlorate.-Cyanosis and asphyxia; 
chocolate-brown color of blood and organs, with 
methemoglobin spectrum; acute hemorrhagic 
glomerulonephritis, with methemoglobin in kid- 
neys, spleen, bone-marrow, and urine. 
Potassium Bichromate.-Changes similar to 
those from potassium chlorate; decomposition 
delayed. 
Hydrogen Sulphid.-Characteristic odor; green- 
ish tint of blood (only found in animal experi- 
ments). 
Alcohol.-Characteristic odor, specially marked 
in brain and liver; odor may be that of aldehyd, 
ether, or mercaptan. Asphyxia, engorgement of 
organs with blood, edema of glottis, lungs, and pia. 
The organs usually present stigmata of chronic 
alcoholism-viz., cyanotic (hog-back) kidneys, 
with diffuse cirrhosis; fatty or cirrhotic liver, milky 
opacity of pia, and chronic or acute gastritis. 
Cantharides.-Inflammation of stomach and 
intestine, with presence of scales in the stomach; 
acute hemorrhagic glomerulonephritis, hemor- 
rhagic pyelitis, and hematuria. 
The following poisons have appearances which, 
while fairly constant and uniform, are not in 
themselves characteristic: 
Morphin, Laudanum, Chloral, and Narcotics.- 
Intense cyanosis and congestion of organs, fre- 
quently bronchitis and commencing hypostatic 
pneumonia. 
In poisoning from strychnin, belladonna, and 
other alkaloids, and in most glucosids, the post- 
mortem conditions indicate death by asphyxia. 
It must be mentioned, also, that this condition is 
found in poisons which produce syncopal effects, 
such as aconite, etc., the anatomic condition de- 
scribed as characteristic of syncope being only a 
figment of medicolegal imagination. With poison- 
ing from digitalin and ptomains diarrhea is often 
a prominent symptom, without inflammatory 
changes in the intestines. 
Anesthetics.-In deaths during anesthesia the 
appearances are usually negative; accidental 
causes of suffocation should be carefully looked for, 
as well as evidences of organic disease. Suffoca- 
tion by inhalation of vomited matters is very fre- 
quently the immediate cause of death in alcoholism 
and carbon monoxid poisons, and occasionally is so 
in other poisons. 
The recent work showing that ricin, abrin, and 
other substances produce cell-necrosis in the liver 
and kidney, indicates a field in which investigation 
is needed, and might give valuable diagnostic re- 
sults. The leukocytosis in arsenic and other poisons 
may prove of importance in the future. The swell- 
ing and hemorrhagic condition characteristic of 
snake-venom, and the cell changes produced by the 
bacterial toxins, have important bearings on toxi- 
cology. So also has the role which secondary 
bacterial infection plays in poisoning cases, though 
as yet data on this are too meager to permit of 
generalization. 
In the foregoing article prominence has not been 
given to the minor technic details of autopsy 
routine. Those who are not thoroughly familiar 
with autopsy methods will probably serve best 
their own interests and those of the public by not 
attempting work of this kind. When such a per- 
son cannot avoid the responsibility, his best plan 
would be to remove all the organs with as little 
dissection as possible, and bring them, untouched 
and uncontaminated, into the hands of some more 
competent person. 
POLIENCEPHALITIS.-See Brain (Inflamma- 
tion). 
POLIOMYELITIS, ACUTE ANTERIOR.-See 
Paralysis (Infantile). 
POLIOMYELITIS, ACUTE IN ADULTS (Acute 
Atrophic Spinal Paralysis of Adults').-Very rarely 
in adults under 30 occurs a disease almost identical 
with the infantile form, though mistakes in diag- 
nosis have been made, the disease being in reality 
multiple neuritis. 
POLIOMYELITIS, SUBACUTE AND CHRONIC 
(General Anterior Spinal Paralysis, Subacute of Duch- 
enne, Subacute and Atrophic Spinal Paralysis).- 
Cases have occurred, though rarely, characterized 
by paralysis and atrophy of all extremities without 
sensory disturbance, and without the severe onset 
of the acute form. It has often been mistaken 
for multiple neuritis. 
POLITZERIZATION.-See Ear (Examination). 
POLLANTIN (Dunbar's Serum).-An antitoxic 
serum from horses treated with pollen toxin de- 
rived from ragweed. It is used in the pro- 
phylaxis and treatment of hay fever. See Serum 
Therapy. 
POLYCYTHEMIA.-Marked increase in the red 
blood cells is generally indicative merely of concen- 
trated blood or stasis. It occurs in health after 
bathing, massage, violent exercise. It is observed 
in high altitudes and follows the administration of 
certain drugs. It may occur during digestion, 
in blood regeneration, vomiting, profuse sweating, 
the removal of exudates, profuse diarrheas and, it 
is said, with myxedema and acute yellow atrophy. 
It is found in circulatory derangements, such as POLYDIPSIA 
POPLITEAL ANEURYSM 
organic heart disease, emphysema, stenotic dysp- 
nea. See Blood. 
POLYDIPSIA.-Excessive thirst. It is usually 
present in fevers and in diabetes. See Thirst. 
POLYNEURITIS.-See Neuritis (Multiple). 
POLYPUS.-A pedunculated tumor arising from 
mucous membranes. The nose is a frequent seat 
of polypi. Uterine polypi are of three kinds-- 
cystic, derived from the ovules of Naboth; mucous 
or soft, resembling rectal polypi; and hard or 
fibrous, the so-called fibrous polypus of the uterus. 
Polypi of the ear resemble nasal polypi, springing 
from the tympanic membrane and from the interior 
of the tympanum. Intestinal polypi are of more 
frequent occurrence in the rectum than in any 
other portion of the intestinal tract. They are 
composed of tissue resembling that of the mucous 
membrane of the part, and are mostly described 
as adenomata. Polypi are also found in the blad- 
der, larynx, on the gums, and sometimes in sinuses 
communicating with the nose. See Nose, Uterus. 
POLYURIA.-Excessive secretion of urine. 
The causes of temporary polyuria are: excessive 
ingestion of fluids, cold, suppression of perspira- 
tion, the use of diuretics; it occurs in the crisis of 
fevers, and in certain neurotic conditions, as hys- 
teria, and in nervous excitement. A permanent 
polyuria is met in diabetes mellitus, diabetes 
insipidus, chronic interstitial nephritis, and in 
amyloid disease of the kidneys. See Diabetes, 
Nephritis, Urine (Examination). 
POMEGRANATE.-See Granatum. 
POMPHOLYX.-A rare inflammation of the 
hands and feet generally of the palmar and plantar 
surface, resulting in the formation of vesicles and 
blebs, occurring in adults. The majority of cases 
are met with in neurotic women. The vesicles are 
deep-seated and resemble boiled sago grains; they 
may disappear by absorption or become purulent 
or coalesce to form large, flat blebs. The disease 
is usually symmetric and lasts from a few weeks to 
several months. It must not be confounded with 
eczema or rhus poisoning. Treatment consists in 
improving the general health by tonics and good 
food and keeping the bowels open. Soothing ap- 
plications are indicated locally. 
PONS, DISEASES.-Tumors of the pons produce 
symptoms chiefly of pressure. Of 52 cases, 13 
had cerebral nerves involved, in 13 the limbs were 
affected, and in 26 hemiplegia and nerve involve- 
ment existed. Twenty-two of the latter had 
alternate paralysis. In 4 no motor symptoms 
presented. 
Hemorrhage into the pons and medulla oblon- 
gata is rarer than cerebral hemorrhage and more 
frequent than hemorrhage into the spinal cord. 
Atheroma or miliary aneurysm and other factors 
productive of increased arterial tension are usually 
coincident, while cardiac hypertrophy, nephritis, 
excessive bodily exertion, and alcoholism may be 
traced. 
Lesions involving the pyramidal tract cause 
crossed paralyses. A lesion in the lower part of 
the pons will cause a lower segment paralysis of the 
face on the same side, and a spastic paralysis of 
the arm and leg on the opposite side. The abdu- 
cens, the motor part of the trigeminal, and the 
hypoglossal nerves may likewise be paralyzed. 
When the central fibers to the nucleus of the hypo- 
glossus are involved, a peculiar form of anarthria 
follows. Swallowing is interfered with if the 
nucleus itself is involved. A paralysis of the 
external rectus muscle of one eye and of the inter- 
nal rectus of the other eye, in the absence of a 
"forced position" of the eye-balls, is highly char- 
acteristic of certain lesions of the pons. The in- 
ternal rectus may still be capable of convergence. 
This conjugate paralysis may be complicated by 
other disturbances of eye-muscle movements, and 
the facial nerve is often involved in these paralyses. 
In lesions of the pons the patient has a tendency 
to fall to the side on which the lesion is situated. 
Still more frequent is the simple motor hemi- 
ataxia consequent upon lesion of the medial lemnis- 
cus and possibly the longitudinal bundles in the 
formatio reticularis. Only when the lesions are 
very extensive are there disturbances of hearing. 
Treatment should conform to that of cerebral 
hemorrhage. Electricity is indicated for the 
paralysis. 
POPLITEAL ANEURYSM.-The popliteal artery 
is the most common seat of aneurysm, except the 
aorta itself. It is peculiarly liable to atheroma; 
it is not supported by the structures around; it is 
compressed more or less in flexion of the knee, 
stretched out in overextension, sometimes even 
ruptured; and immediately below it breaks up into 
a number of branches, so that an embolus, if it 
comes down the vessel, is almost certain to lodge 
there. That constitutional causes are of very 
great importance is shown by the fact that it some- 
times occurs on both sides, and that it may even 
develop upon the second while the patient is lying 
in bed being treated for the first. Fusiform dila- 
tation occasionally occurs, but sacculated aneurysm 
is much more common. In some cases it springs 
from the anterior surface of the artery and grows 
forward against the bone or the posterior ligament 
of the knee-joint, and then it is usually slow in its 
course, rarely attaining a large size. In others it 
extends backward, and, meeting with little to 
oppose it, becomes immense, forming a thin-walled 
sac within a comparatively short space of time. 
Symptoms.-Occasionally the onset is sudden, 
dating from some exertion; more frequently, the 
patient suffers from obscure rheumatic pain down 
the leg, with stiffness of the joint and sense of 
weakness, and then suddenly discovers, or has 
discovered for him, the presence of a pulsating 
swelling. Usually the expansive pulsation, the 
bruit conducted down the leg, and the way in which 
the sac empties upon compression and fills again on 
relaxation of the vessel are distinctive. Occasion- 
ally the tumor is harder and cannot be emptied, 
the pulsation is that of an artery only, and the 
bruit is indistinct and faint; and in some very rare 
instances there is no pulsation at all. Probably, 
in the former case, the sac is already partly filled 
with fibrin, and possibly in the latter it is com- 
pletely solid; but as pulsation sometimes makes its 
appearance later, this explanation is hardly satis- 
factory. If the sac grows forward, synovitis of POPPY 
POSTMORTEM EXAMINATION 
the knee-joint sets in, the pain is very severe, and 
movement greatly restricted. If it takes a direc- 
tion backward, the popliteal vein may be com- 
pressed and congestion and edema follow; or the 
internal popliteal nerve may be stretched so that 
there is severe neuralgia extending down the side 
of the limb into the sole of the foot. Sometimes a 
distinct difference can be made out in the two 
tibial pulses. 
Left to itself it occasionally undergoes sponta- 
neous cure. Much more frequently it grows larger 
and larger, leaks, and ruptures either into the knee- 
joint, or more usually into the cellular tissue of the 
leg. In either case the patient is conscious of 
something having given way, and becomes sick 
and faint with the pain and loss of blood. If the 
rupture takes place through the posterior ligament, 
the knee becomes immensely distended at once, 
but the bruit and pulsation do not cease alto- 
gether, and the pulse can still be felt, though 
feebly, in the posterior tibial. If it is into the 
cellular tissue, a tense swelling forms rapidly in 
the popliteal space, filling it completely and caus- 
ing the most severe pain; the limb below becomes 
cold and livid, the tibials cannot be felt, and in a 
very short time gangrene sets in. Occasionally 
inflammation breaks out round the sac, the skin 
becomes red, edematous, and exceedingly painful, 
and sometimes this is followed by suppuration. 
The differential diagnosis must be made from 
sarcoma growing either from the bones, the pos- 
terior ligament of the knee-j oint, or the lymphatic 
glands; abscess; bursal cyst, or diverticulum from 
the knee-joint; and solid tumors resting upon the 
artery. Arterial hematoma from perforation of 
the popliteal artery gives rise to the same symp- 
toms as a leaking or a ruptured aneurysm, accord- 
ing to the size of the opening. Sometimes there 
is a distinct bruit with faint pulsation along the 
course of the vessel. 
Treatment.-Rest and diet are employed only as 
adjuncts, but they should never be neglected, and 
unless the sac is enlarging rapidly, so that there 
is fear of rupture, it is always advisable to submit 
the patient to a few days' preparation before 
employing any active treatment. If the aneurysm 
is of moderate size only, and there is no fear of 
immediate rupture, Reid's method with Esmarch's 
bandage, or digital compression, is the best, pref- 
erence being given to the latter if there is much 
evidence of atheroma or of heart-disease; to the 
former if, other things being suitable, there are 
enlarged glands in the groin. Flexion succeeds 
well with aneurysms that are small or already 
partially solidified. If these measures fail, or if 
the sac is enlarging rapidly and perhaps leaking, or 
if inflammation has set in, or if there is any 
edema of the foot from pressure upon the popliteal 
vein, surgical treatment should be resorted to. 
Matas' operation of aneurysmorrhaphy has 
been practised with success in popliteal aneurysm, 
and is to be preferred to ligation of the femoral 
artery. See Aneurysm. 
POPPY.-See Opium. 
POSITIONS.-See Fetus (Positions and Pres- 
entations.) 
POSTMORTEM EXAMINATION.-The general 
technic of a postmortem is as follows: First,the 
appearance of the body is described, including sex, 
height, apparent age, discoloration of the skin, 
rigor mortis, state of the nutrition, injuries, defor- 
mities, and any peculiarities that may be observed. 
An incision is then made from the top of the 
sternum to the pubic symphysis, the abdomen be- 
ing the cavity first opened. Then the position of 
the viscera, their condition, the presence of 
hernia, if it exists, the state of the peritoneum, 
and the quantity of fluid are noted, but all with- 
out disturbing the relation of the contents. The 
thorax is now opened. In order to do this, the 
ribs are divided at the costochondral junction, and 
the sternum and clavicles disarticulated. The 
relation of the structures exposed on lifting up the 
separated portion of sternum and ribs is noted- 
the presence of fluid in the pleural cavity, pleural 
adhesions, the extent to which the lung covers 
the pericardium. The pericardial sac is next 
opened, and its condition and the quantity of fluid 
recorded. 
The opening of the heart is the next step. This 
may be done in several ways; one of the best is 
Virchow's method. The heart is opened in situ. 
The first incision is made in the right ventricle 
(many open the right auricle first), along the 
ventricular ridge, from near the auriculoventricu- 
lar groove to near the apex. The second incision 
opens the right auricle midway between the 
entrances of the venae cavae. In the left auricle 
the incision is carried from the left superior pul- 
monary vein to near the auriculoventricular ring. 
The incision through the left ventricle begins just 
behind the base and ends just short of the apex. It 
must be carried deeply through the wall of the 
heart. The heart is now removed. To do this the 
organ is grasped with the index-finger of the left 
hand in the left ventricle and the thumb in the 
right; the heart is then raised by the apex and the 
venae cavae, the pulmonary veins, and the pulmo- 
nary artery, and the aorta divided, taking care that 
the incisions are not too close to the heart. The 
next step is to open the ventricles. For this pur- 
pose the heart is placed exactly in the position 
it occupied in the body. One blade of the scissors 
is then introduced near the lower end of the in- 
cision in the right ventricle, and carried outward 
in the direction of the pulmonary artery. The 
incision for the left ventricle commences at the 
apex of the heart and divides the anterior wall of 
the ventricle close to the septum, and is continued 
outward. 
The lungs are next removed, usually the left first. 
Section of these organs is made by a long sweep of 
the knife-in the case of the left preferably from 
the apex to the base; in the case of the right, from 
the base to the apex. Attention is now directed 
to the abdomen, the spleen being the first organ 
removed. 
Next come the suprarenals and the kidneys. In 
order to gain access to these it is wise to dissect off, 
by a few quick cuts, the entire colon from the sig- 
moid flexure to the ileocecal valve. A double 
ligature is placed around the sigmoid, and the gut POSTMORTEM EXAMINATION 
POSTPARTUM HEMORRHAGE 
divided between the ligatures. The removal of 
the kidneys is further facilitated by cutting the 
diaphragm loose from its costal attachments and 
throwing it upward, with the liver, into the tho- 
racic cavity. The adrenals and kidneys are then 
exposed; the course and condition of the ureters 
are noted. The suprarenals may now be removed 
separately, or taken out with the kidneys; in either 
case it is best to remove the organs on the left side 
first. Section is made of the adrenals; also of the 
kidneys. In the latter the capsule is stripped off, 
and a note is made of the extent, if at all, to which 
it is adherent; also whether the renal substance is 
tom on removing the capsule. 
The next step consists in the removal of the 
intestines. These are cut closely to their mesen- 
teric attachment, care being taken to leave as little 
of the mesentery attached to the gut as possible. 
The fecal contents are then washed out by a run- 
ning stream of water through the bowel, which is 
opened at the attachment of the mesentery and 
examined. In removing the intestines the rec- 
tum and the first and second portions of the duo- 
denum are left in situ. The next step is usually the 
opening of the stomach and remaining portion of the 
duodenum. This is accomplished, like the open- 
ing of the intestines, by means of the entero tome. 
After the duodenum is opened, the gall-bladder 
is pressed until bile is made to flow from the mouth 
of the common duct in the duodenum. If this is 
impossible, obstruction exists. The gastric con- 
tents are described, and the condition of the 
walls noted. The pancreas is now examined, 
the condition of its duct, and the presence of cysts 
or stones being noted. It is then removed and 
incised longitudinally. 
The liver is next taken out, the condition of the 
vessels entering the portal fissure having been 
noted before they were divided. The liver is 
weighed and measured transversely, longitudinally, 
and vertically, the width of the two large lobes 
being taken separately. A long incision is now 
made into the substance of the organ and the con- 
ditions noted, especially the relation of the con- 
nective tissue to the hepatic substance proper. 
The pelvic organs are next removed. This is 
best accomplished by first making a cut into the 
bladder; into the opening a finger is inserted, 
while the other fingers grasp the rectum. By 
making the tissues tense, their separation from the 
bony wall of the pelvis is facilitated. After re- 
moval they are cut open; in the case of a female 
subject the uterus is opened by a longitudinal cut 
through the anterior wall. A fine probe is passed 
into the oviducts to ascertain their patulousness; 
they may also be opened by a delicate pair of 
scissors. 
Nothing of importance remains now in the abdo- 
men except the vessels and the semilunar gan- 
glia. The latter should be examined in situ and 
also after removal. The aorta should be opened 
by a longitudinal incision extending from the 
beginning of the arch down to its bifurcation, 
thence prolonged out into the iliac arteries. The 
thoracic duct should be looked for at the side of 
the aorta. The trachea, larynx, thyroid gland, 
pharynx, and tongue can be removed either 
through a median incision in the front of the neck 
or from the base of the neck. 
For the removal of the brain it is necessary to 
saw out a portion of the cranial vault. It is cus- 
tomary to divide the scalp about on a line with 
the coronal suture. The vault is sawed through 
in front and behind, a large, wedge-shaped piece 
being removed. The dura is then divided on a 
line with the sawed edge of the bone, and also 
separated from the attachment to the crista galli 
in front. The brain is then carefully lifted from 
its bed, the nerves passing from it divided, and the 
attachment of the dura to the petrous portion of 
the temporal bone cut loose. If possible, the 
pituitary body should be kept attached to the 
brain. 
A long knife is now introduced into the spinal 
canal, and the cord cut as low down as possible. 
The brain is then lifted out and placed on a board 
or plate. After a careful survey of its external 
appearances, the organ is dissected. A number of 
methods are in vogue. One of the best is that 
known as Edinger's method; only its general 
features can be indicated here. The lateral ven- 
tricles are first opened; then the cerebral hemis- 
pheres are cut away from the basal ganglia. 
Longitudinal and transverse cuts are made into 
the cerebral mantle, observing always to make the 
incisions as near as possible at right angles to the 
course of the convolutions. The basal ganglia 
are examined by making multiple incisions into 
them; the cerebellum is similarly treated. 
The spinal cord is generally removed from the 
back; special saws have been devised to cut the 
pedicles of the vertebrae. The cord itself is re- 
moved in its membranes from below upward, the 
most important point being the avoidance of 
traction. The membranes are opened, and the 
cord substance divided at short intervals by 
transverse cuts. The eyes, if it is necessary, can 
be removed without difficulty. The removal of 
the organ of hearing requires considerable labor. 
All organs should, if possible, be weighed. 
POSTPARTUM HEMORRHAGE.-Hemorrhage 
during and after the third stage of labor. Should 
it occur after the first 24 hours of the puerperium, 
it is called puerperal hemorrhage. 
Postpartum hemorrhage may be divided into: 
(1) Hemorrhage from relaxation of the uterus; 
(2) hemorrhage from rupture of the uterus; (3) 
hemorrhage from inversion of the uterus; (4) 
hemorrhage from lacerations of the lower birth 
canal, and (5) hemorrhage into the perivaginal 
tissues (hematoma). 
Hemorrhage from Relaxation of the Uterus.- 
This is one of the most common forms of post- 
partum hemorrhage, and is what is meant when 
the simple term "postpartum hemorrhage" is 
used. 
Causes.-Any condition which interferes with 
firm contraction of the uterus after the explusion 
of the child might be mentioned as a cause of 
postpartum hemorrhage. Of these conditions may 
be mentioned weakness of the uterine muscle from 
overdistention; general disease; faulty develop- POSTPARTUM HEMORRHAGE 
POSTPARTUM HEMORRHAGE 
ment; mental anxiety; retained placenta, mem- 
branes, or blood-clots; old adhesions; tumors, 
and distended bladder and rectum. 
Symptoms.-The important symptom is hemor- 
rhage, which may appear before or after the ex- 
pulsion of the placenta. There may be sudden gush 
of blood, profuse enough to destroy the patient in a 
f ew moments; or there may be a succession of gushes, 
a few ounces of blood being lost every few seconds. 
Not infrequently there is a steady flow of blood 
from the uterus, which will only end with the 
death of the patient or with the most active 
treatment. Palpation shows a large relaxed 
uterus, and there are marked constitutional signs 
of hemorrhage, such as extreme pallor, vertigo, 
sighing respiration, and, possibly, syncope. The 
pulse is extremely weak and rapid, or it may be 
entirely absent at the wrist. 
Treatment.-The proper management of the 
third stage of labor, followed by the application of 
an abdominal pad and binder, is the best pre- 
ventive treatment of postpartum hemorrhage. 
When one has special cause to fear hemorrhage, 
as in case of multiple pregnancy, hydramnios, 
and the like, a good precautionary measure is the 
hypodermic injection of 3 to 5 grains of ergotin as 
soon as the child's head is born. 
In the majority of instances a postpartum hemor- 
rhage may be quickly controlled by external 
stimulation of the uterus. The fundus is grasped 
by the hand through the abdominal wall, and is 
pinched, kneaded, and irritated until, in favorable 
cases, it becomes firm and hard and the bleeding 
ceases. If the placenta is not yet expelled, it 
should be expressed by the Crede method. If 
the foregoing procedure fails to control the bleed- 
ing, the disengaged hand should be passed into 
the uterine cavity and all placenta, membranes, 
and blood-clots should quickly be removed. 
This internal stimulation of the uterus will usually 
prove most effective. Should this fail and should 
the hemorrhage be rather slight in amount, 
hot douching may next be tried. A fountain 
syringe is filled with plain boiled water at a 
temperature of 120° F., and this thrown well up 
into the uterine cavity by means of a large two- 
way metal catheter. Should the bleeding be 
alarming in quantity or should this latter method 
fail, the last and most effective method of treat- 
ment is the use of the intrauterine tampon. The 
best material for plugging the uterus is 5 percent 
iodoform gauze. The patient is brought across 
the bed with the buttocks extending well over the 
edge; the anterior and posterior lips of the uterus are 
each grasped with a double tenaculum and drawn 
well down toward the vulvar orifice. The end of 
the gauze is seized with dressing forceps and, 
guided by two fingers of the left hand, introduced 
into the cervix and pushed well up to the fundus; 
the dressing forceps are now removed and suc- 
cessive portions of the gauze are carried up until 
the uterine cavity is firmly packed from above 
downward. If the packing is done properly, 
from 3 to 5 yards of gauze will be required. This 
is followed by packing the vagina, either loosely or 
tightly as may be indicated. In exceptional 
cases when the uterus is entirely atonic, it may be 
necessary to reinforce the vaginal tampon by a 
large perineal pad and binder, the two ends of the 
binder being firmly attached to the abdominal 
binder. 
The subsequent treatment will depend upon 
the amount of blood the patient has lost, and upon 
her general condition. After a moderately severe 
hemorrhage it will be sufficient to remove the pil- 
low from under the patient's head and raise the 
foot of the bed; to give some rapidly acting 
cardiac stimulant; hypodermic injections of ether, 
brandy, or carbonate of ammonium; to give fre- 
quently repeated teaspoonful doses of strong hot 
coffee, hot water and brandy, hot milk, red wine, 
or champagne; and to surround the patient with 
hot bottles, and cover her with warm blankets. 
When the anemia is extreme, it is necessary, in 
addition to the preceding, to replace the lost fluid 
as quickly as possible. This is done most readily 
by the injection of a normal salt solution-about 
40 grains of NaCl to the pint of warm 
water-into the large intestine. Two or 3 pints 
of this solution, if retained will cause a very 
marked and rapid improvement in the pulse. 
If the bowel will not retain this solution, it 
should be given subcutaneously. A cannula 
about the size of a rye-straw is attached to the 
rubber tube of a fountain syringe; the syringe, 
placed about 6 feet above the patient, is filled with 
a sterile salt solution; the cannula is plunged directly 
into the cellular tissue underneath the mammary 
gland, starting at the outer periphery of the gland; 
the fluid is allowed to drain into the tissues until 
a pint or more has been absorbed. Both breasts 
may be filled with this solution, or the loose tissue 
in the axilla or between the scapulae may be 
selected for this purpose. Autotransfusion (band- 
aging the extremities and thus forcing the blood 
into the vital organs) will be found a useful ad- 
junct. After the patient has reacted, a hypo- 
dermic injection of morphin (1/6 grain) will quiet 
her, and probably induce a much-needed sleep. 
Hemorrhage from Rupture of the Uterus.- 
Rupture of the uterus is one of the rarest accidents 
of labor, occurring once in about 4000 cases. 
The position of the rent is most frequently in the 
lower uterine segment. Occasionally, the rupture 
is an incomplete one, involving the mucous and 
muscular coats only. 
Causes.-The most frequent cause is some se- 
rious obstruction to labor, such as grave degrees 
of contracted pelvis, malposition of the child, 
and tumors obstructing the pelvic canal. Any 
conditon weakening the uterine wall, such as fatty 
degeneration of the muscle, or a previous cesarean 
section, predisposes toward rupture. External 
traumatism may be mentioned as a rare cause. 
Symptoms.-Rupture of the uterus may occur 
at any time during labor, but it occurs most fre- 
quently during the second stage. A prolonged 
second stage of labor, with frequent severe pains, 
thinning of the lower uterine segment, and rise of 
the contraction ring, should be looked upon with 
apprehension, as they are premonitory signs of 
rupture. At the time of rupture there are usu- POSTPARTUM HEMORRHAGE 
POSTURE 
ally violent pain and a sensation as though some- 
thing had "given away." There are pronounced 
shock, rapid weak pulse, pallid, leaking skin, fall 
of temperature, and sighing respirations. 
Physical Signs.-The os is widely dilated; the 
membranes are ruptured; the presenting part, 
unless it has been firmly engaged, recedes; the 
uterine contractions cease, and the child may 
plainly be felt in the abdominal cavity. It may 
be possible to feel the rent in the uterus, with 
perhaps loops of intestines projecting through it. 
Rupture of the uterus may occur, rarely, without 
any of these symptoms-the rent being discovered 
during efforts at the removal of the placenta. 
In rare instances the uterus may rupture during 
the puerperium as a result of pressure necrosis, 
septic ulceration, or malignant degeneration of 
the deciduae. The symptoms and treatment are 
those of septic infection. 
Prognosis.-This depends largely upon the 
extent of rupture, the amount of hemorrhage, the 
cleanliness with which labor has been conducted, 
and the treatment. The mortality is variously 
given at from 55 to 90 percent. The two chief 
dangers are hemorrhage and sepsis. 
Treatment.-This will depend upon the condi- 
tions present. Rupture of the uterus can be pre- 
vented, usually, by the proper treatment of labor 
complicated by contracted pelves, by correction of 
malpositions, and the like. 
If the child is delivered before the rent is diag- 
nosed, the treatment will depend upon the amount 
of hemorrhage. The placenta should be delivered 
immediately and a hypodermic injection of ergotin 
administered. If the hemorrhage is slight, a strip 
of iodoform gauze may be introduced into the rent 
to secure drainage. No further treatment is 
necessary except the removal of the gauze at the 
end of 24 hours. It the child is not delivered and 
is still in the uterine cavity, it must be extracted 
immediately by forceps, version, or craniotomy. 
If it has been extruded into the abdominal cavity, 
laparotomy must be performed immediately. In 
all cases when the rent is large, when the hemor- 
rhage is great, and when it is believed that septic 
material has escaped into the peritoneal cavity, 
the abdomen must be opened, the peritoneal 
cavity cleansed, and the uterus amputated, or the 
rent closed, as may be indicated. When a con- 
servative plan of treatment is at first pursued, it 
may be necessary to open the abdomen later on 
account of the occurrence of septic infection. 
Hemorrhage from Inversion of the Uterus.- 
This is an extremely rare accident. It may occur 
before or after the expulsion of the placenta. 
Causes.-Effort to secure delivery of the pla- 
centa by traction on the cord is probably the most 
important cause. Precipitate labor and paralysis 
of the placental site have also been mentioned as 
causes. 
Symptoms.-The important symptoms are shock 
and hemorrhage. The former is most marked, the 
latter is variable. Pain may be present, although 
it is not a constant symptom. 
Physical Signs.-A soft, round, tumor protrudes 
from the vulva. To it may be attached all or por- 
tions of the placenta. The orifices of the fallopian 
tubes may be seen on either side. The finger 
passed along the side of the tumor at its apparent 
attachment feels the symmetrically reflected cervix 
surrounding it. Abdominal palpation shows an 
absence of the fundus, a cup-shaped depression, 
containing, perhaps, the tubes and ovaries, being 
felt instead. 
Prognosis.-This is very grave unless the uterus 
can be quickly replaced. Shock, hemorrhage, and 
sepsis may be causes of death. 
Treatment.-This consists in immediate reposi- 
tion. The uterus is grasped in such a manner that 
the fundus rests upon the palm of the hand, the 
fingers and thumb surrounding the reflected 
portion of the cervix. The vaginal part of the 
cervix is gradually dilated with the tips of the 
fingers, and the body of the uterus is passed stead- 
ily upward and forward until reduction is com- 
plete. If the placenta is adherent, it should be 
removed before attempting replacement. 
Hemorrhage from Lacerations of the Lower 
Birth Canal.-Lacerations of the lower birth canal 
resulting in profuse hemorrhage are situated in the 
cervix, anterior vaginal wall, near the urethra, or 
about the clitoris. Inspection of the cervix, 
vagina, and vulva will speedily make the diagnosis. 
Treatment.-If of the cervix, a tampon of iodo- 
form gauze packed closely around the vaginal 
aspect will quickly control it. In very rare cases 
it may be necessary to suture it. If of the anterior 
vaginal wall or about the clitoris, a provisional 
tampon may be introduced, which is subsequently 
removed and the tear closely sutured. 
Hemorrhage into the Perivaginal Tissues.-This 
is a rather infrequent complication of labor. It 
may occur in the labia, underneath the vaginal 
wall, or in the broad ligament. 
Causes.-A varicose condition of the veins, 
which is so constant an accompaniment of preg- 
nancy, is the predisposing cause. The exciting 
cause is the traumatism inflicted by the passage of 
the child; or it may be due to the use of forceps or 
other manipulations in securing delivery. 
Symptoms.-Sharp pain is felt at the time of 
rupture, and, in exceptional cases, there may be 
signs of internal bleeding. 
Physical Signs.-A bluish tumor, varying in size 
from a walnut to a fetal head, may be seen at the 
vulva, or may be felt in the vagina. It gradually 
increases in size, and is elastic or fluctuating. 
Very rarely it may rupture externally, causing 
profuse hemorrhage. 
Prognosis.-If properly treated, the prognosis is 
favorable. The most serious complication is in- 
fection of the blood-clot. 
Treatment.-If the bleeding does not subside 
spontaneously, it should be controlled by pressure 
and the application of ice. Subsequently, absorp- 
tion should be encouraged by absolute quiet, clean- 
liness, and protection. If suppuration should 
occur, free incisions, with irrigation and drainage, 
must be resorted to. In exceptional cases it may 
be necessary to incise the tumor, turn out the clot, 
and ligate the bleeding point. 
POSTURE.-See Gynecologic Examination. POTASSIUM 
POULTICE 
POTASSIUM.-K = 39; quantivalence i; specific 
gravity 0.865. A metallic element, of silvery 
luster, and characterized by intense affinity for 
oxygen. Its peculiar reactions are its precipita- 
tion when converted into the acid tartrate, its 
precipitation by platinum perchlorid, and the 
violet color it imparts to the flame. Physiolog- 
ically, salts of potassium are protoplasmic poisons 
when applied locally in sufficient concentration. 
They dialyze more readily than sodium salts. In 
the body they occur especially in the solid struc- 
tures, while sodium salts predominate in the fluids. 
In large doses by the mouth, potassium salts act 
as irritants to the gastrointestinal tract. The 
circulation is generally depressed by potassium 
salts-after small doses the primary depression of 
the pulse-rate and arterial pressure is followed by 
a rise of both; large doses cause a rapid fall of 
pressure and pulse-rate. Injected into a vein, 
salts of potassium cause paralysis of the heart. 
Potassium salts are obtained from the ash of 
plants, from saltpeter, from the potassium bitar- 
trate deposited from urine in the process of fer- 
mentation, and from the washings of sheep's wool. 
The action of the various salts is given under their 
proper headings. 
Preparations.-P. Acetas, KC2H3O2, an easily 
soluble salt having marked diuretic properties. 
Dose, 5 grains to 1 dram. Purgative doses, 2 to 
4 drams. P. Arsenitis, Liquor, Fowler's solution. 
See Arsenic. P. Bicarbonas, KHCO3, a salt 
with properties like the carbonate, to which it is 
preferable. Dose, 5 to 45 grains. P. Bitartras, 
KHC4H4O8. See P. Tartras. Dose, 20 to 60 
grains as a diuretic; 1/2 to 1 ounce as a purgative. 
P. Bromid, KBr, a colorless, crystalline, bitter 
salt, readily soluble in water. It is extensively 
employed as a sedative in nervous excitement, 
and is one of the best drugs in epilepsy. Its pro- 
longed use causes the condition known as Brom- 
ism (g. v.). P. Carbonas, K2CO3, used locally 
in acne and acute eczema, internally in rheumatism, 
in the uric acid diathesis, and in jaundice. Dose, 
2 to 20 grains. P., Caustic, potassium hydroxid. 
P. Chloras, KC1O3, a crystalline compound, with 
a saline, cooling taste. It is soluble in 15 or 16 
parts of cold, and readily soluble in boiling, water. 
It is used as a gargle in diseases of the mouth and 
throat, in mercurial stomatitis, etc. Dose, 1 to 10 
grains. In toxic doses it causes disorganization 
of the blood (converting the hemoglobin into 
methemoglobin) and intense irritation of the kid- 
neys, with hematuria and blood casts. Sir 
James Y. Simpson recommended it, in doses of 
20 grains thrice daily, in threatened abortion from 
fatty degeneration of the placenta. P. Chloratis, 
Troch., each containing 2 1/2 grains of the salt. 
Dose, 1 to 3. P. Citras, K3C8H6O7.H2O, is used in 
solution as a febrifuge, a diuretic, and to alka- 
linize the urine. Dose, 10 to 30 grains. P. 
Citratis, Liq., citric acid 6, potassium bicarbonate 
8; filter and add enough distilled water to make 
50 parts. Dose, 1/2 to 1 ounce. P. Citras Effer- 
vescens consists of the citrate 20, sodium bicar- 
bonate 47, tartaric acid 25, and citric acid 16. 
Dose, 1 to 2 drams in a glass of water as an effer- 
vescing drink. P. Cyanid., KCN, made from potas- 
sium ferrocyanid by the action of heat, sometimes 
with (also without) the addition of potassium 
carbonate and charcoal. It is very soluble in 
water, has active reducing powers, and is very 
poisonous. It has the sedative and antispas- 
modic action of hydrocyanic acid, and, like it, is 
used in gastric irritability and cough. Dose, 1/20 
grain. P. Dichromas. Synonym of P. Bichromas. 
An antiseptic and escharotic milder than chromic 
trioxid. Internally it has been efficient in chronic 
nasal, gastric, or intestinal catarrh, chronic ulcers 
of the mouth and pharynx, chronic bronchitis, 
laryngitis, rheumatism, locomotor ataxia, some- 
times in diphtheria. Dose, 1/10 to 1/2 grain in 
trituration. Locally it is used in aqueous solu- 
tion (5 grains to 1 dram to the ounce). P. et 
Sodii Tartras, KNaC4 H4O8.4H2O, " Rochelle salt," 
laxative. Dose, 1 to 4 drams. P. Ferrocyanid, 
K4FeC8N8 + 3H2O, yellow prussiate of potash, pre- 
pared from blood, and by heating together animal 
charcoal, iron, and pearl ash. It occurs in yellow 
crystals, soluble in water. It has many uses in 
chemic analysis. P. Hydroxidum, KHO, potassa, 
"caustic potash," deliquescent and very alkaline. 
A powerful escharotic. P. Hydroxidi Liquor, an 
aqueous solution of about 5 percent of P. Hydroxid. 
Dose, 5 to 30 minims, well diluted with water. 
P. Hypophosphis. See Phosphorus. P. lodid., 
KI, used in syphilis, metallic poisoning, and as an 
antirheumatic. Dose, 2 to 20 grains. See 
Iodin. P. Nitras, KN03, saltpeter, niter, crys- 
tallizing in long white prisms. Commercially, it is 
prepared by double decomposition of potassium 
chlorid and Chili saltpeter, sodium nitrate. Dose, 
5 to 20 grains, well diluted P. Permanganas. 
See Manganese. P. Sulphas, K2SO4, a hepatic 
stimulant and laxative; soluble in 10 parts of water 
at ordinary temperature. Dose, 10 to 45 grains. 
Pulvis Efferves. Comp., compound effervescing 
powder, "Seidlitz powder," contains in the blue 
paper potassium bitartrate, 120 grains, mixed with 
sodium bicarbonate, 40 grains; and in the white 
paper, tartaric acid, 35 grains. 
POTT'S DISEASE.-See Spine (Caries). 
POTT'S FRACTURE.-See Ankle (Fracture). 
POULTICE (Cataplasm).-Generally employed 
as a means of applying heat and moisture to a 
certain portion of the body, but is sometimes 
medicated with anodyne, counterirritant or dis- 
infectant agents. An excellent method of pre- 
paring poultices is to make several bags of various 
sizes, of either of the fabrics known as Swiss and 
cheese-cloth, filling each bag half full with the lin- 
seed meal or other agent used, then sewing up the 
open end. When wanted for use one of these bags 
is submerged in boiling water for a few minutes, 
and on taking it out the meal is found to have 
swelled so as to fill the bag, which should then 
be squeezed to rid of superfluous water, laid 
on the part and covered with oiled silk and a 
bandage. 
The ordinary filthy poultice of flaxseed, slippery 
elm, bread and milk, has no place among the re- 
sources of the aseptic surgeon. The common 
poultice is a hot-bed for bacteria, and as such, it POWDER 
PREGNANCY, DIAGNOSIS 
should be discarded. In the treatment of an 
ordinary furuncle with poultices, almost every 
surgeon must have seen occasionally the develop- 
ment of innumerable minute daughter-furuncles in 
the surface covered by the poultice. In phleg- 
monous inflammation of the fingers or hand, the 
prolonged use of the poultice is followed by 
maceration of the skin, extensive edema of the 
superficial structures, a flabby condition of the 
granulation-in fact all the evidences which point 
to the poultice as a means of favoring the extension 
of the infectious process (Senn). 
A sinapism is a poultice or plaster containing 
mustard (sinapis), used for the purpose of counter- 
irritation. If applied too hot and kept on too long 
the skin will become inflamed and ulcerated, and 
extensive gangrenous sores may result. 
The only poultice official in the U. S. P. is the 
catapalsma kaolini, in which glycerin is the active 
agent. It consists of kaolin, 577 gm.; boric acid, 
45 gm.; thymol, 0.5 gm.; methyl salicylate, 2 gm.; 
oil of peppermint, 0.5 gm.; glycerin, 375 gm.; to 
make 1000 gm. 
Fomentations.-Flannel may be wrung very dry 
out of boiling water, applied, and covered with 
oiled silk. Spongiopiline, a fabric composed of 
sponge and wool, coated with india-rubber, is an 
excellent vehicle for the application of warmth and 
moisture. The inner surface is moistened with hot 
water, and its utility may be increased by sprin- 
kling the moistened surface with charcoal or yeast 
or by saturating it with any desired lotion or 
liniment. 
POWDER (Pulvis).-In pharmacy one or more 
medicinal substances reduced to a state of very fine 
division. Powders are usually prepared extempo- 
raneously, but a few compound ones have been 
made official, the ingredients being simply rubbed 
together until reduced to a fine powder and thor- 
oughly mixed. Special directions are given in a 
few instances. Powders are usually mixed on a 
slab with a spatula, but, except in the case of explo- 
sives, a much better method is trituration in a 
mortar. 
There are 9 official powders: 
Title. 
Constituents. 
Properties 
and Dose. 
Pulvis: 
Glycyrrhiz® Com- 
P. senna, 180 gm.; p. 
licorice, 236 gm.; 
washed sulphur, 80 
gm.; oil fennel, 4 
gm.; sugar, 500 gm. 
P. ipecac, 10 gm.; p. 
Laxative, 60 gr 
positus (licorice 
powder). 
Ipecacuanhas et Opii 
Diaphoretic, 8 
(Dover's powder). 
Jalaps Compositus. 
opium, 10 gm.; sugar 
of milk, 80 gm. Ten 
grains contain a 
grain each of the 
active constituents. 
P. jalap, 35 gm.; po- 
gr. 
Cathartic, 30 
Morphins Composi- 
tass. bitart., 65 gm. 
Morph, sulph., 1.5 
gr. 
Diaphoretic, 8 
tus (Tully's pow- 
der). 
Rhei Compositus.... 
gm.; p. camphor, 32 
gm.; p. licorice, 33 
gm.; precip. calc, 
carb., 33.5 gm. 
P. rhubard, 25 gm.; 
gr 
Laxative, ant- 
magnesia, 65 gm.; 
p. ginger, 10 gm. 
acid, 30 gr. 
POX.-See Syphilis. 
PREDIGESTED FOOD.-See Peptonized Food. 
PREGNANCY.-The state of the female corre- 
sponding to the presence within her body of the 
product of conception; the period from conception 
to delivery. When delivery is protracted far 
beyond the normal time and the ovum is dead, the 
condition of pregnancy cannot be said to exist. 
The normal duration of pregnancy in woman is 
280 days, or 10 lunar months of 28 days each, 
or 9 calendar months. Various methods have 
been devised to estimate the probable termination 
of pregnancy, one of which, Ely's table, is in- 
troduced under Confinement. 
PREGNANCY, DIAGNOSIS.-The signs of preg- 
nancy may be divided into subjective and objective. 
The subjective signs are those which are appre- 
ciated by the mother. Arranged in the order of 
their importance, they are: (1) Cessation of men- 
struation; (2) nausea and vomiting; (3) change 
in the size and shape of the abdomen; (4) change 
in the genitalia and breasts; (5) quickening; and 
(6) change in the nervous system. These signs, 
taken alone, are of slight importance, but when 
they are considered in connection with the objec- 
tive signs, they become of considerable value. 
The objective signs are those which are ascer- 
tained by employing the senses of sight, touch, 
and hearing. 
Inspection shows splotches of pigmentation on 
the face and dark circles under the eyes. The 
breasts are enlarged, the nipples are prominent, 
the areola is widened and darkened, a secondary 
areola is developed, the glands of Montgomery are 
enlarged, and pressure on the breast from the 
periphery toward the nipple will cause the appear- 
ance of a drop or two of turbid fluid-colostrum. 
The abdomen is symmetrically enlarged, striae 
are present, the umbilicus is pigmented, and after 
the sixth month of gestation projects from the 
surface of the abdomen, and fetal movements can 
be seen. The mucous membrane of the vulva and 
vagina is dark purple in color. 
Palpation ascertains the size and shape of the 
uterus; the intermittent uterine contractions; and 
Title. 
Constituents. 
Properties 
and Dose. 
Pulvis: 
Acetanilidi Com- 
Acetanilid, 70 gm.; 
Relieves pain, 
positus (Antikam- 
caff ein, 10 gm.; so- 
8 gr. 
nia ?). 
Aromaticus 
dium bicarb., 20 gm. 
P. cinnamon, 35 gm.; 
Aromatic, 15 
Cretse Compositus.. 
p. ginger, 35 gm.; p. 
cardamon, 15 gm.; 
p. nutmeg, 15 gm. 
Prep, chalk, 30 gm.; 
gr. 
For chalk mix- 
Effervescens Com- 
acacia, 20 gm.; sugar, 
50 gm. 
Sodium bicarb., 31 gm.; 
ture, 30 gr. 
Laxative, 1 set 
positus (Seidlitz 
Rochelle salt, 93 gm.; 
of 2 powders. 
powder). 
tartaric acid, 27 gm.; 
mix the sod. bicarb, 
and Roch, salt, and 
divide into 12 pts. 
(blue papers). Di- 
vide the t. acid into 
12 pts. (white papers). PREGNANCY, DISEASES 
PREGNANCY, PERNICIOUS VOMITING 
in advanced cases the position of the fetal back, 
head, and extremities. Vaginal examination shows 
softening of the cervix and lower uterine segment; 
change in the shape, size, and consistency of the 
uterus; and ballottement. See Ballottement. 
Auscultation reveals the fetal heart-sounds, the 
uterine souffle, and at times the funic souffle. 
For convenience of clinical diagnosis it is best 
to divide the signs of pregnancy into three groups: 
1. Those manifesting themselves during the 
first three months are: Cessation of menstruation, 
nausea and vomiting, enlargement of the breasts, 
soft cervix and lower uterine segment, and change 
in the size, shape, and consistency of the uterus. 
2. During the second three months there are, in 
addition to the foregoing, intermittent uterine 
contractions, ballottement, fetal movements and 
heart-sounds, and purple discoloration of the 
vaginal mucous membrane. 
3. During the last three months, in addition it is 
possible to ascertain the position of the back, 
head, and extremities, and to determine the pre- 
senting part. 
Of these signs, ballottement, fetal heart-sounds, 
and fetal movements are considered absolutely 
diagnostic. 
-t PREGNANCY, DISEASES.-These are considered 
under their appropriate headings. See Amnion, 
Chorion, Eclampsia, Colon Bacillus Infec- 
tion, Nephritis of Pregnancy, etc. 
PREGNANCY, DURATION.-See Confinement. 
PREGNANCY, EXTRAUTERINE OR ECTOPIC. 
-See Extrauterine Pregnancy. 
PREGNANCY, FALSE.-See Pseudocyesis. 
PREGNANCY, MULTIPLE.-Two or more fecun- 
dated ova or fetuses occupying the uterus at the 
same time. Twin births occur once in about 
100 cases, triplets occur once in about 8000, and 
quadruplets once in about 400,000 cases. Twin 
pregnancy occurs when 2 ova are fecundated at or 
near the same time; or two fetuses may develop 
from a single ovum. If the twins are developed 
from 2 ova, each twin has its own amnion, chorion, 
and placenta; if from 1 ovum, there is but one 
chorion and placenta. 
The diagnosis of multiple pregnancy is difficult, 
and is usually not made until birth. Irregularity 
in the shape and excessive size of the abdomen 
would be suggestive. Edema of the lower part of 
the abdominal wall and lower extremities is a 
common sign, while the presence of an abnormal 
number of extremities would be almost diagnostic. 
The only positive signs are: The existence of 2 
fetal heart-sounds, of different rates, heard with 
greatest intensity at different points on the ab- 
domen; and the palpation of two heads, two 
breeches, or multiple extremities. 
The prognosis for both mother and child is 
somewhat graver than in single pregnancy. The 
dangers to the mother are albuminuria and eclamp- 
sia, postpartum hemorrhage, and a long, tedious, 
and complicated labor. The children are likely 
to be ill developed from lack of room; monsters, 
from anastomoses between fetal and placental 
vessels, frequently occur, and usually there are 
serious complications at birth. 
The treatment of labor in multiple pregnancy is 
the same as in ordinary pregnancy until the first 
child is born. After this has occurred the cord 
should be ligated and the position and presenta- 
tion of the second child determined. If this is 
faulty, as it frequently is on account of the roomi- 
ness of the uterus, it should be corrected immedi- 
ately, and a dram of the fluidextract of ergot 
administered. The second child is usually born 
within an hour after the first; a longer delay than 
this demands some artificial interference. 
PREGNANCY, PERNICIOUS VOMITING.-The 
variety of vomiting occasionally seen in pregnancy 
that becomes so excessive as to thi eaten the 
patient's life. 
Causes.-The causes of pernicious vomiting are 
extremely varied. The most common are: (1) 
Reflex disturbance, caused by the rapid growth 
and distention of the uterus, with irritation of 
its contained nerve endings; (2) some pathologic 
condition of the uterus or its adnexa, such as endo- 
metritis or inflammation of the tubes and ovaries; 
(3) some pathologic condition of the gastro- 
intestinal tract, such as gastritis or gastric 
ulcer; (4) excessive sexual intercourse; (5) kidney 
insufficiency. 
Symptoms.-The ordinary physiologic vomiting 
of pregnancy becomes exaggerated until the 
patient vomits almost continuously. Anything 
taken into the stomach is immediately vomited, 
and with it bile-stained mucus. Blood is not 
infrequently mixed with the vomited material. 
The mere sight or thought of food is enough to 
provoke an attack of vomiting. There is intense 
thirst; the patient becomes extremely weak and 
emaciated; the temperature is usually subnormal; 
the respirations are rapid; the pulse becomes 
rapid and feeble; coma supervenes, and death 
occurs from profound exhaustion. 
Diagnosis.-The diagnosis of the condition is 
easy, while that of the cause of the condition is 
difficult. From the fact that it occurs early in 
pregnancy, usually from the second to the fourth 
month, the existence of pregnancy may be over- 
looked. Should the vomiting occur late in 
pregnancy, kidney disturbance should be sus- 
pected. 
Prognosis.-The prognosis is grave. In general 
practice the mortality ranges from 25 to 50 percent. 
Treatment.-The patient should be confined to 
bed in a quiet, darkened room. The bowels should 
be kept freely open, and a suitable diet given. 
This should consist of easily digestible foods, such 
as milk, broths, eggs, and the like. Sexual inter- 
course must be prohibited. Should any local excit- 
ing cause be found, it should, if possible, be re- 
moved. Thus, a displaced uterus should be re- 
placed; erosion of the cervix or inflammation of 
the cervical canal should be treated by the appli- 
cation of a solution of silver nitrate (20 grains to 
the ounce); inflammation of the tubes and ovaries 
may be treated by the careful use of tampons and 
douches. Drugs that allay nervousness are some- 
times beneficial; grain doses of the aqueous extract 
of opium by suppository, or 10-grain doses of 
sodium bromid in a dessertspoonful of camphor PREMATURE LABOR 
PRESBYOPIA 
water may be given 3 or 4 times daily. Other 
drugs that have been found useful at times are: 
Cocain (1/4 of a grain), silver nitrate (1/4 of a 
grain), oxalate of cerium (10 grains), hydrobro- 
mid of hyoscin (1/120 of a grain), antipyrin 
(8 grains), tincture of aconite (6 minims), tincture 
of iodin (2 minims), tincture of nux vomica (10 
minims), and creosote (1 minim). 
If the patient cannot retain any food by the 
mouth, all efforts in this direction should cease 
and she should be fed by the rectum. If this is 
properly done, life may be sustained for days or 
even weeks. The following rules should be 
observed in rectal alimentation: (1) The enema 
must consist of predigested food. A very good one 
is the following: Three ounces of peptonized milk, 
2 ounces of liquid peptonoids, 1/2 of an ounce of 
whisky, and 15 drops of tincture of opium. (2) 
The enema should not exceed 6 ounces in quantity. 
(3) It should be given regularly at intervals of 4 or 
5 hours. (4) It should be preceded by irrigation 
of the lower bowel with a normal salt solution. 
If the patient fails to improve under this course 
of treatment, the induction of abortion is indicated. 
This final step in the treatment of pernicious 
vomiting must not be delayed too long or the 
exhaustion will become so great that it will fail. 
If vomiting continues after 6 or 8 days of rectal 
feeding; if her temperature rises or remains sub- 
normal; if her pulse becomes rapid and weak; 
if, in short, she presents the picture of pronounced 
exhaustion, abortion should be induced immedi- 
ately in the manner already described. Dilatation 
of the cervical canal and internal os with the finger 
has been tried with benefit in a certain proportion 
of cases. It should be given a trial just previous 
to the induction of abortion. 
PREMATURE LABOR.-See Labor (Prema- 
ture) . 
PRESBYOPIA (Old-age Sight).-A condition of 
the eye in which the power of accommodation is 
either partially or wholly lost by age. Properly 
speaking, presbyopia implies diminution of the 
accommodative power in adults past middle life 
to such an extent as to interfere with near vision. 
Presbyopia usually occurs between 40 and 50 years 
of age. As a hyperopic eye is obliged to exert a 
portion of its power of accommodation to over- 
come its refractive error, it necessarily has less 
accommodative power in reserve, and conse- 
quently becomes presbyopic sooner than an emme- 
tropic or myopic eye. An uncorrected myope may 
never exhibit the signs of presbyopia, as he can 
read at his far-point, but if he wears a distant 
correction, he will have the same need for a reading 
glass about the presbyopic age as the emmetrope 
or hyperope. See Ametropia. 
Cause.-The direct cause of presbyopia is the 
diminishing elasticity of the lens; simultaneously 
with the solidification and sclerosing conditions 
which take place elsewhere in the body with 
advancing age. As a consequence of the changes 
in the lens-structure, it gradually loses its power to 
become convex, and hence to refract diverging 
rays from a near-point so that they will meet 
directly on the retina and give a clear image. 
This diminution in the refractive power of the 
lens is physiologic, and when it has advanced to 
such a point that rays at the average reading dis- 
tance-about 13 inches- are no longer refracted 
exactly on the retina, presbyopia is said to have 
commenced. 
Notwithstanding the fact that each patient 
should be studied individually, and no arbitrary 
rules can be constructed by which we can estimate 
the relative range of accommodation to age, for 
convenience it is desirable to have the following 
tables in the mind in refracting presbyopes: 
Age in 
Accommo- 
Age in 
Accommo- 
Years. 
dation IN 
Diopters. 
Years. 
dation in 
Diopters. 
io, 
14 
45, 
3.5 
15, 
12 
50 
2.5 
20, 
10 
55, 
1.75 
25, 
8.5 
60, 
1 
30, 
7 
65, 
0.75 
35, 
5.5 
70, 
0.25 
40, 
4.5 
75, 
0. 
Additional Glass Required to 
Produce a 
Comfortable 
Working 
Ne ar-point. 
45, 
+ 1 D. 
50, 
+ 1.75 D. 
55, 
+ 2.50D. 
60, 
+ 3 D. 
65, or over, 
+ 3.50 D. 
Symptoms.-The chief symptom of recession of 
the near-point beyond the ordinary working 
distance is dimness of vision for near-work, the 
patient particularly complaining of inability to 
read, write, or sew, without holding the work at an 
uncomfortably increased distance. The ordinary 
symptoms of accommodative asthenopia are very 
often present, and it is quite likely that the head- 
aches, dyspepia, and neurotic conditions in women 
about 45 years of age, so often attributed to the 
menopause, are really directly due to eye-strain. 
The gradual progress of presbyopia, together with 
the attempt of nature to remedy the defect by 
narrowing the pupil, somewhat delays the marked 
symptoms, and, unfortunately, most presbyopes 
unconsciously undergo considerable eye-strain 
before seeking the oculist. 
Diagnosis rests on the age of the person, the 
history of failing near vision, the recession of the 
near-point as tested with the Jaeger types, and 
the acceptance of a convex lens at close range. A 
loss of accommodation disproportionate with the 
age is indicative of ciliary palsy or insufficiency. 
Treatment.-In every case it is necessary to 
detect and properly correct the hyperopia, myopia, 
or astigmatism that may exist; and for this 
purpose, in strong, vigorous persons under 50 the 
administration of a mydriatic is necessary. Fol- 
lowing the ordinary method of prescribing lenses 
for distance in the kind and degree of ametropia 
detected, we correct the presbyopia by adding to 
the distant correction a convex spheric lens that 
gives the best vision at an ordinary working 
distance. If allowed to choose the glass and 
distance, the presbyope will usually select a strong 
glass at a close reading point, and thus lead the PRESCRIPTION-WRITING 
PRESCRIPTION-WRITING 
examiner into error. Always try the test-lenses 
with the reading card at least 13 inches from the 
eye. Again, it must be constantly borne in mind 
that the patient's occupation is an important factor 
to be considered in prescribing presbyopic glasses; 
the engraver needs stronger glasses than the seam- 
stress, and, conversely, persons working at a com- 
paratively long distance, such as musicians, 
artists, ministers in the pulpit, etc., need weaker 
glasses in the pursuit of their occupations than 
they do for ordinary reading. 
PRESCRIPTION-WRITING.-A11 h o u g h pre- 
scriptions in good English are preferable to those 
written in incorrect or badly abbreviated Latin, 
the classic formulas of prescription-writing, taken 
from Potter, are given below: 
A prescription should begin with the name of 
the person for whom it is designed, and the date 
on which it is written. Then follows the Latin 
word Recipe, usually abbreviated to the sign 1$, 
and signifying "Take," or "Take thou"; next the 
names and quantities of the ingredients to be used, 
which are also expressed in Latin; then the direc- 
tions to the compounder, followed by the directions 
to the patient, the last being now usually expressed 
in English; and, finally, the signature and address 
of the prescriber. 
A prescription then has four component parts 
-viz.: 
Superscription-consisting of the name of the 
party for whom it is designed, the date, and the 
sign I|, signifying "Take thou." 
Inscription-the body of the prescription, con- 
sisting of one or more of the following subdivisions 
-viz.: 
Basis-or chief active ingredient. 
Adjuvant-to assist the action of the basis. 
Corrective-to correct some injurious quality of 
the other ingredients. 
Vehicle or excipient-giving the prescription a 
suitable form. 
Subscription-the directions for the compounder, 
usually expressed in contracted Latin. 
Signature-the instructions for the guidance of 
the one administering the medicine, in English, 
followed by the signature of the prescriber. 
A prescription may, however, contain the base 
alone, or the base with the adjuvant, or the base 
with a simple vehicle or diluent. A single ingredi- 
ent may serve a double or treble office, as the 
syrupus rhei aromaticus with quinin, in which case 
the syrup serves as an adjuvant to increase the 
action of the quinin, as an excipient to cover the 
taste, and as a vehicle to facilitate the adminis- 
tration of the dose directed. Again, the basis 
may need no aid in doing its work, and may require 
no corrective of its action, nor any special vehicle. 
On the other hand, there is no limit to the number 
of ingredients which may be used, provided that 
the prescriber has a clear idea of something to be 
accomplished by each one, and also provided that 
there is no chemic or medical incompatibility 
between them. The tendency of the present age 
is toward monopharmacy, rather than poly- 
pharmacy. However, proper combinations of 
medicines will often produce effects for the 
patient's good which could not be obtained from 
the use of any one remedy. 
Procedure in Writing a Prescription.-In writing 
an extemporaneous prescription, the first step is to 
write the patient's name and address, the date, and 
the sign 1$. The physician's registration number 
is also necessary if the prescription contains opium 
or cocain, or any salt or derivative of opium or 
cocain. (See Harrison Law). Then the title of 
each ingredient should be written in Latin and in 
the genitive case, except that when a certain num- 
ber only of an ingredient is ordered, the name of 
the ingredient should be in the accusative case: 
for example, Vitellum unum, "one yolk of egg." 
Next, the quantity of each ingredient sufficient for 
one dose should be mentally determined and multi- 
plied by the number of doses which the mixture is 
to contain, and the result set down in signs and 
Roman numerals. The directions to the pharma- 
cist and patient being added, and the prescriber's 
name or initials affixed, the prescription is com- 
pleted; but when very active agents are used, it is 
a good plan to go over the calculations a second 
time before letting it leave the hands of the person 
most responsible for its action. For pills or pow- 
ders the same process should be employed, slightly 
varied according to the requirements of each case. 
Frequently, the ingredients and quantities for but 
one pill, powder, or suppository are named, with 
instructions to make a certain number after the 
formula. When an unusually large dose of any 
poisonous drug is prescribed, it is customary to 
underline the quantity. 
An example will perhaps make the foregoing 
more comprehensible, and at the same time serve 
to indicate the style of Latin writing formerly 
employed. The following formula is that ordered 
in the U. S. P. for the preparation known as Black 
draft, but officially styled the compound infusion 
of senna, approximate weigths and measures being 
substituted for the pharmacopeial metric weights: 
For Mrs. John Black. January 1, 1911. 
Recipe, Take,- 
Super- 
scription. 
(Basis.) 
r Sennce, semiunciam, 
I Of senna, half an ounce. 
I Magnesii sulphatis, 
I Of magnesium sulphate. 
f Mannce, ana unciam unam, 
I Of manna, of each an ounce. 
InscRiP- 
TION. 
(Adjuvant.) 
(Corrective.) 
'Fceniculi, drachmam, 
. Of fennel, 1 dram. 
(Vehicle.) 
Agues bullientis, fluiduncias octo 
Of boiling water, 8 fluidounces 
Macera per horam in vase clauso, deinde cola. 
Macerate for an hour in a closed vessel, then 
strain. 
Subscrip- 
tion. 
Signetur, Let it be entitled-A wineglassful 
every 4 hours until it operates. 
Charles White, M.D. 
Signa- 
ture. 
The above prescription abbreviated would read: 
For Mrs. John Black. January 1, 1911. 
I}. Sennse, g ss 
Magnesii sulphat., 
Mannse, aa g j 
Fceniculi, g j 
Aquae bull., g viij. 
Mac. per hor. in vase clauso, deinde cola. 
Sig.-A wineglassful every 4 hours, until it 
operates. C. White, M. D. PRESCRIPTION-WRITING 
PRESCRIPTION-WRITING 
TABLE OF PRESCRIPTION DOSES AND QUANTITIES (Potter). 
Grains in 
Entire 
Mixture. 
Grains in Each 3 Dose in a Mixture of 
Grains in 
Entire 
Mixture. 
Grains in Each 3 Dose in a Mixture of 
3j 
3ij 
3 iij 
3iv 
3vj 
3 viij 
3xij 
Sxvj 
3j 
5ij 
3 iij 
3iv 
3vj 
3viij 
3xij 
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Explanation.-In writing a prescription look for the dose of the ingredient (say 1/20 grain) in the column headed by 
the size of your mixture (6 ounces); then on that line, in the left marginal column, is the quantity (2 1/2 grains) you must 
put into the entire mixture to get your dose in each dram thereof. In reading a prescription find the quantity of any 
ingredient called for in the left marginal column (say 3/4 grain), and on the same line, in the column headed by the number 
of ounces in the mixture (3 ounces), you will find the quantity (1/32 grain) in each dram dose. Of course, when the dose is 
more or less than 1 dram, the result must be proportionately multiplied or divided accordingly. PRESENTATIONS, FETAL 
PROSTATE GLAND, HYPERTROPHY 
As the result of the above is nearly identical 
with the official preparation, we might write the 
same prescription more simply, as follows: 
I}. Infusi Senn® Compos., 5 viij. 
with the proper superscription and signature; this 
being the manner of prescribing the official 
preparations. 
A rule for writing a prescription in metric terms 
by one who is not practised in the use of the system 
is the following, by Potter: 
Write as though prescribing but one dose of each 
ingredient in grains or minims and decimals thereof; 
then substitute the term "grams" or "cubic centi- 
meters" for grains or minims, and the prescription 
is correct for 15 doses in metric terms. 
Of course, when writing for a mixture or solution, 
the proper quantity of vehicle must be added to 
complete the one dose, and must also be expressed 
first in grains or minims. For example: 
india-rubber strapping, air-cushions and water- 
cushions, and bags filled with sand or shot are 
other means. Digital pressure may sometimes be 
useful in compressing an artery. Successive layers 
of collodion make considerable pressure. 
PRESSURE SYMPTOMS.-1. Nervous symp- 
toms due to pressure upon the brain or spinal cord. 
In general if the pressure is light, the symptoms 
are those of irritation of the area pressed upon, 
manifesting themselves as spasmodic movements, 
tonicity of the muscles, pain, hyperesthesia, etc.; 
if the pressure is great, there results paralysis- 
motor or sensory or both-of the parts innervated 
by the areas pressed upon. See Brain, Spinal 
Cord. 2. The symptoms produced by an an- 
eurysm or a tumor, as of the pelvis, adjacent 
organs being impinged upon. 
PRIAPISM.-See Penis, Spine (Injuries). 
PRICKLY HEAT.-See Sweat Glands. 
PRISMS.-See Eye-muscles. 
PROCTITIS.-'See Rectum (Inflammation). 
PROCTOCLYSIS.-Continuous rectal irrigation, 
popularized by Murphy, has proved of inestimable 
value in the treatment of peritonitis, hemorrhage, 
and shock. It is also recommended in typhoid, 
scarlatina, eclampsia, and the first stage of pneu- 
monia. The nozzle of the apparatus is bent in 
order that it may be inserted without pressure 
against the posterior rectal wall as the patient 
sits up in bed. An adhesive strip fastens the tube 
to the thigh. The tube may remain in position 
several days. Murphy introduces a pint and a 
half of the solution (1 dram each of sodium chlorid 
and calcium chlorid to the pint of water) into the 
rectum in about an hour, then after an interval of 
an hour, a similar quantity is introduced. A 
modified form of irrigator has an electric heater 
attached to the douche so that the water entering 
the rectum can be kept at a constant temperature 
of 100° F. Saline solution may be administered 
by the drop method by means of a special instru- 
ment, containing a glass sight tube and a hard 
rubber regulator, designed to eliminate the dis- 
advantages of the continuous flow method (back 
flow of fluid, regurgitation of feces, difficult re- 
tention of fluid in some cases). Through this 
contrivance, too, gases can readily escape. The 
Elbrecht apparatus, recommended by Dr. Mur- 
phy as fulfilling all indications, is adapted for 
either the continuous or the drop method. See 
Peritonitis. 
PROFESSIONAL NEUROSIS.-A neurosis 
caused by continuous exercise of one set of muscles. 
See Occupation Neuroses. 
PROGRESSIVE MUSCULAR ATROPHY.- 
Chronic anterior poliomyelitis in which the large 
ganglion cells of the anterior horns, the motor and 
trophic cells of the muscles, are gradually de- 
stroyed. See Muscles (Atrophy). 
PROLAPSE.-See Anus, Ovary, Rectum, Um- 
bilical Cord, Uterus, etc. 
PROSTATE GLAND, HYPERTROPHY.-The 
term hypertrophy of the prostate is applied to that 
form of enlargement of the gland which takes place 
after middle life, rarely before the fiftieth year, 
and more frequently after the age of 60, developing 
One Dose. 
15 Doses 
Metric. 
I). Quininse sulphatis, gr. j, 
Strychninse sulphatis, gr. or 0.016, 
1 
016 
Fluidextr. glycyrrhizse, ttjj iv, 
Syrupi, njj lx, 
4 
60 
This gives a two-ounce mixture approximately, of 
which the dose w'ould be a teaspoonful. 
One Dose. 
15 Doses 
Metric. 
3. Quininse sulphatis, 
gr. j, 
1 
Massse ferri carb., 
gr. ij, 
2 
Extr. nucis vomicae, 
Ft. pil. no. xv. 
gr. | or 0.25, 
25 
Sig.-One pill thrice daily after meals. 
See Dosage; Latin (Medical); Incompati- 
bility. 
PRESENTATIONS, FETAL.-See Fetus (Posi- 
tion and Presentation). 
PRESSURE.-Pressure is a less ambiguous term 
than compress or compression. Illustrations of the 
mechanic uses of pressure are: Coaptation of di- 
vided parts, crushing and dispersion of a ganglion 
on the wrist, truss retention of hernia, dilatation of 
strictures by bougies, and injections of air or oil 
by the rectum in cases of intussusception. The 
therapeutic uses of pressure, in combination with 
immobility and rest, antiseptics, and styptics are 
hemostatic, antispasmodic, and antiphlogistic in 
nature. In arresting hemorrhage, by most 
methods, in preventing and in treating acute in- 
flammation when from a bruise or injury to a joint, 
gentle, equable, and elastic pressure conduces 
powerfully to the balance of innervation and cir- 
culation. In chronic inflammation pressure is a 
powerful agent. The patient's comfort is the 
usual measure of the degree of pressure in each 
case. When pressure causes pain, it must at once 
be lessened. Well-adjusted and elastic pressure is 
of service in the treatment of simple flesh wounds, 
complicated fractures, ingrowing toe-nail, in burns, 
bubo, carbuncle, whitlow, and arthritis. Bandag- 
ing is the most usual form of applying pressure, 
with or without padding, while elastic bandages, PROSTATE GLAND, HYPERTROPHY 
PROSTATE GLAND, HYPERTROPHY 
slowly and without inflammatory symptoms. 
The enlargement may be general, affecting the 
entire organ equally, or it may take the form of a 
circumscribed growth involving only one portion 
of the gland. Thus, the so-called middle lobe 
alone may be involved. Overgrowth in this 
situation may take the form of a pedunculated 
tumor or of a sessile hypertrophy. In other cases 
there is a hyperplasia of the lateral lobes without 
any involvement whatever of the median portion. 
Sometimes one lateral mass is much more affected 
than the other. 
In one form of this affection there is a marked 
overgrowth in a transverse direction, just at the 
vesical orifice, which gives rise to an upward pro- 
jection that offers a great impediment to the 
emptying of the bladder. To this particular con- 
dition the term "collar" has been applied. There 
are two distinct types of prostatic hypertrophy. In 
one the overgrowth affects chiefly or entirely the 
glandular elements, forming a tumor of the type of 
the adenomata. In the other form the increase 
affects the stroma, which results in the formation 
of a fibroma-like tumor. Between these two types 
there is every gradation of simultaneous involve- 
ment of both gland and stroma. 
Etiology.-The etiology of this form of prostatic 
enlargement has not been definitely determined. 
Many theories have been advanced, but, so far, 
none of them is susceptible of complete demon- 
stration. Thus Launois advanced the hypothesis 
that the condition is merely a part of a universal 
arteriosclerosis, or local sclerosis affecting the 
urinary organs, and Ciechanowski endeavored to 
prove that it is the terminal result of chronic 
gonorrheal inflammation. Neither of these theo- 
ries, however, has been generally accepted, and 
in fact good evidence has been adduced to show 
that they are wrong. Other supposed causes such 
as chronic constipation, sexual excesses, gout, 
rheumatism, the abuse of alcohol, etc., are so 
fanciful as to require no consideration whatever. 
Symptoms.-The symptoms of enlargement of 
the prostate are not referred to the organ itself, 
but to the function of urination. In a certain 
percentage of cases with a moderate degree of 
hypertrophy there will be no symptoms to direct 
the patient's attention to the presence of this con- 
dition. As the overgrowth is of slow and gradual 
formation, so the symptoms are usually so in- 
sidious that the patient does not notice the change 
until the condition is well advanced. Usually, 
the earliest symptom is an increase in the fre- 
quency of urination. The difference in the begin- 
ning is very slight, but as the condition goes from 
bad to worse, the patient may be called upon to 
empty the bladder as often as every hour, half- 
hour, or even 15 minutes. In some cases this in- 
creased frequency is more particularly noted 
during the hours of sleep. There is also more or 
less hesitation in the beginning of micturition and 
absence of the usual force, which results in the 
loss of the usual parabolic curve, and, finally, an 
incomplete stoppage. Pain is a marked symptom 
in some instances, and is absent in others. It is 
particularly marked in the cases complicated with 
acute inflammation of the bladder. Some forms 
of prostatic hypertrophy obstruct the outflow of 
urine to a marked degree, while others seem to 
offer no obstacle to this function. In the former 
class the patient is unable entirely to empty the 
bladder. The urine that remains after the patient 
passes as much as possible is termed "residual." 
In some instances the patient is unable to void 
any urine voluntarily; in other cases it collects 
until the bladder is filled to its utmost capacity, 
after which there is an involuntary "dribbling," 
which flows as fast as the secretion is discharged 
from the kidneys. If cystitis is superadded, the 
urine will contain pus and mucus proportionate in 
amount to the grade of the inflammation, and 
blood will very frequently be present also. In a 
few cases the very first symptom will be absolute 
retention, which is the result of cold or some other 
condition, producing an acute congestion of a 
gland already the seat of a marked hypertrophy. 
Diagnosis.-The diagnosis of hypertrophy of the 
prostate is usually to be made by digital palpation 
through the rectum. This examination reveals 
enlargement of the lateral lobes only, but will not 
always detect with certainty an overgrowth of the 
median portion. It is necessary, however, to 
exclude other sources of obstruction and other 
disturbances of the function of urination. Among 
the conditions from which prostatic enlargement 
is to be distinguished are: Stricture of the urethra, 
atony and paralysis of the bladder, tumor of the 
bladder, calculus, and cystitis. Stricture of the 
urethra will be detected readily by the usual ex- 
amination for this condition. Atony of the bladder 
results from prolonged overdistention or from 
profound depression of the general health. Paral- 
ysis of the bladder would be accompanied by 
other evidences of degenerative changes in the 
spinal cord. Tumors of the bladder and tuber- 
culosis are more difficult to distinguish from hy- 
pertrophy of the prostrate. A careful study of 
the history and the symptoms is necessary, and, 
finally, the usual examination for the latter con- 
dition will generally enable one to determine its 
presence or absence. Vesical calculus will be de- 
tected by careful examination with the proper 
instrument. It should not be forgotten, however, 
that vesical calculus and prostatic hypertrophy 
frequently coexist, the latter condition predis- 
posing to the formation of stone. The differentia- 
tion from simple cystitis must be made again by 
excluding enlargement of the prostate. 
The positive evidence of prostatic enlargement 
is determined, as already indicated, by digital 
examination through the rectum, and, in addition, 
by careful instrumental examination of the ure- 
thra. In making the latter examination the follow- 
ing points should be noted: (1) The distance the 
catheter passes before urine begins to flow; (2) 
whether the point of the catheter deviates to 
either side or is otherwise obstructed as it reaches 
the prostatic portion of the urethra; and (3) 
whether it is necessary to depress the shaft more 
than usual between the thighs before the point 
of the instrument enters the bladder. 
This exploration is in most instances best made PROSTATE GLAND, HYPERTROPHY 
PROSTATE GLAND, HYPERTROPHY 
with a full-sized metal catheter (24 to 28 of the 
French scale) that has been properly sterilized 
and lubricated. It is also necessary to pass a 
catheter immediately after the patient has voided 
as much urine as possible voluntarily, in order to 
determine whether there is any residual urine. If 
the catheter passes freely and if urine is withdrawn 
when the instrument has been passed 7 1/2 inches, 
it is to be presumed that marked enlargement 
does not exist. If it is necessary to introduce a 
catheter 8 or 9 inches, or even further, before 
urine flows, and if, in addition, it is necessary to 
depress the shaft forcibly, prostatic enlargement 
is probably present. In certain cases it will be 
found impossible to introduce the ordinary form 
of metal catheter. In these cases it will be neces- 
sary to employ the metal "prostatic" catheter, 
which has a larger curve and a longer shaft than 
the ordinary instrument. In other instances, 
on account of the irregular overgrowth and con- 
sequent tortuosity of the urethra, some of the 
forms of flexible catheters must be employed. 
The information obtained by the foregoing ex- 
amination will be confirmed or disproved by 
digital examination through the rectum. In 
making this examination the patient should lie in 
the dorsal position. The middle finger is the 
most suitable for this exploration. The physician 
should, of course, be familiar with the size of a 
normal prostate-which is usually described 
as being about that of the common horse-chestnut 
- in order to detect the presence of any enlarge- 
ment. It is well, at the same time, to determine 
as far as possible the character of the growth, 
whether uniform or affecting principally one 
lateral lobe; and also whether it is hard or soft, 
hardness indicating fibrous overgrowth and soft- 
ness glandular hypertrophy. Every grade of 
hypertrophy exists, from a degree scarcely to be 
detected, to the size of an orange or even larger. 
A gland that is twice the normal size must be 
considered the seat of distinct enlargement. It is 
to be remembered that the degree of obstruction 
and the urgency of the other symptoms do not de- 
pend entirely upon the extent of the enlargement. 
The cystoscope, if skilfully used, will impart 
much information concerning the condition of the 
prostate. The projection of the enlarged gland 
into the bladder can be plainly seen, as can also 
the narrow channel formed by the convergence 
of the right and left lobes toward the median line; 
in lesser degrees of hypertrophy the irregular 
margin of the sphincter is shown. The so-called 
third lobe may also be distinctly seen, jutting out 
into the bladder. In addition the state of the 
bladder may be ascertained. 
Treatment.-The treatment of these cases is to 
be determined by the symptoms and not by the 
degree of the enlargement of the prostate. As 
in the treatment of every other condition, no 
rules can be given that will be of universal appli- 
cability. Particular indications must always re- 
ceive due consideration. Casper has truly stated 
that great knowledge and much patience is re- 
quired of the surgeon who assumes the respon- 
sibility of treating prostatic cases. Attention 
to hygiene is of great importance. The diet 
should be plain but nutritious, a moderate amount 
of exercise taken, the bowels kept regular, and 
everything known to predispose to congestion and 
engorgement of the prostate avoided. Conse- 
quently exposure to cold and dampness must be 
guarded against as it-often precipitates an attack 
of acute retention. Many prostatics get along 
excellently by following this regimen of living. 
If in course of time occasional attacks of pain, 
strangury and difficulty in urinating occur, relief 
will often be afforded by rest in bed, the use of 
hot applications to the hypogastrium, together 
with hot sitz-baths and the internal administra- 
tion of anodynes and urinary antiseptics. In 
these attacks of incomplete retention recourse to 
the catheter is frequently necessary, but there 
are cases, as already stated, in which the trouble 
subsides promptly under the treatment above 
indicated. 
In cases of complete retention regular catheter- 
ization must of course be practised. Great care 
is necessary in this procedure, which must be 
carried out under the strictest aseptic precautions, 
with the greatest gentleness, and by means of 
properly selected instruments. As a rule soft 
catheters should be used, and of these the French 
silk-web ones are an excellent type. The pre- 
liminary injection of a weak cocain and adrenalin 
solution, followed by an injection of warm ster- 
ilized olive oil or 20 percent gomenol oil, just 
before the catheter is inserted into the urethra, 
will facilitate the passage of the instrument and 
also lessen the pain incident to the procedure. 
In exceptional cases other instruments such as 
Mercier's, Guyon's, Brodie's, or an ordinary 
English catheter bent to a certain curve, will 
render good service, but it is advisable that they 
be used only by one who is well skilled in the 
manipulation of urethral instruments, lest a false 
passage be made. After the urine is withdrawn 
the bladder may be washed out with hot normal 
salt solution. A saturated solution of boric acid 
or weak permanganate solution, for instance 
1:8,000. In cases in which there is an associated 
purulent cystitis, nitrate of silver solution is of 
value. 
For those patients who are more or less de- 
pendent upon the catheter, the internal adminis- 
tration of such drugs as urotropin, arbutin, salol, 
opium and hyoscyamus or belladonna will prove 
helpful if they are selected in accordance with the 
indications present in the individual case. They 
are especially valuable during temporary retention 
in the comparatively early cases as they render 
the urine aseptic and relieve irritability and pain. 
Permanent catheterization is of decided value in 
certain cases, but no fixed rules can be laid down 
with regard to its employment. When the passage 
of an instrument is very painful to a patient 
suffering with prolonged complete retention, the 
permanent catheter may be tried. If it produces 
so much irritation that the patient cannot be made 
comfortable with a moderate amount of opium, 
it is well to discontinue its use. Patients vary 
greatly with reference to their toleration of this PROSTATE GLAND, INFLAMMATION 
PROSTATE GLAND, INFLAMMATION 
instrument, and each case must be decided upon 
its own merits. 
Acute complete retention may demand capillary 
puncture of the bladder if an instument cannot be 
passed through the urethra after a reasonable 
effort has been made to get one through. This 
little operation is free from danger. The skin is 
incised above the symphysis and the trocar plunged 
quickly and forcibly downward and backward. 
With regard to operative treatment suprapubic 
and perineal prostatectomy chiefly require con- 
sideration. They are to be welcomed as a decided 
advance in the therapy of prostatic hypertrophy, 
inasmuch as they afford relief in a class of cases 
not otherwise amenable to treatment. They 
are not without danger, however, and therefore 
should not be employed indiscriminately nor 
undertaken lightly, being reserved for those 
cases in which milder measures prove futile 
(Casper). 
When catheterization fails or has to be fre- 
quently repeated owing to smallness of the bladder 
produced by thickening of its walls, when it is very 
painful or is followed by hemorrhage, and when 
severe cystitis is present or frequent attacks of 
retention occur, then one of these ^radical opera- 
tions is to be considered (Casper). Although 
both operations have ardent advocates, it is 
probable that each has its own particular sphere 
of applicability. Thus it may be stated that the 
large, soft adenomatous prostate which projects 
up into the bladder can be better attacked and 
removed through the suprapubic incision, and that 
the small, hard, fibrous prostate which does not 
rise into the bladder for any distance can be better 
removed by the perineal route. Naturally those 
operators who have had unusual experience in the 
performance of one or the other operation can do 
it successfully under conditions which would make 
its performance very difficult to a surgeon of less 
experience. The suprapubic operation still has a 
higher death rate than the perineal, but it is 
claimed by many that the results obtained by it 
are better and more permanent than those which 
follow the perineal operation. 
The Bottini operation, or galvanoprostatotomy, 
is rarely employed at present. Casper states that 
as a rule it is only palliative, although in a few 
specially selected cases it affords permanent relief. 
Castration for the purpose of producing atrophy 
of the enlarged prostate is a relic of the past, and 
division of the vasa deferentia is employed only in 
case of patients who suffer from prostatism or re- 
curring epididymitis due to catheterization. When 
advanced arteriosclerosis, grave cachexia, bilateral 
renal disease, or other serious organic trouble is 
present so that a radical operation is not possible 
relief may be obtained by the establishment of a 
suprapubic fistula. 
PROSTATE GLAND, INFLAMMATION.-In- 
flammation of the prostate may be either acute or 
chronic. Two forms of each are described-namely, 
follicular and parenchymatous. In the former the 
pathologic process affects the follicles chiefly or 
solely, while in the latter all the structures of the 
organ are involved. 
Etiology.-Acute prostatitis probably does not 
occur as an "idiopathic" affection. Among the 
causes assigned are such external influences as ex- 
posure to cold and wet, and traumatism of the 
perineum; such local factors as injury from in- 
strumentation, calculus, or foreign body; and such 
general conditions as gout and the acute infectious 
diseases. It is probable that all the cases are due 
to infection, and that the factors mentioned act 
chiefly by establishing a focus of diminished re- 
sistance. The majority of cases of inflammation 
of the prostate are secondary to extension back- 
ward of a specific urethritis. The prostate is also 
involved in some cases of cystitis, the condition 
being known as " prostatocystitis." Acute pros- 
tatitis may develop during the course of smallpox, 
scarlet fever, typhoid fever, typhus, etc., or it may 
occur as a sequel to one of these diseases. Prosta- 
titis of tubercular origin is occasionally met with. 
There appears to be no evidence that horseback 
riding and bicycle riding, under proper conditions, 
have ever caused inflammation of the prostate. 
The cases that have been reported as originating 
from these causes may have depended upon other 
factors that were not manifest. This expression 
is not intended to convey the idea that the use of a 
saddle constructed upon principles that are grossly 
wrong anatomically and injudicious riding may not 
exert some unfavorable influence upon structures 
adjacent to the perineum. These are factors, 
however, that may be eliminated, and should not 
be allowed to weigh against the many advan- 
tages to be derived from judicious riding. It 
has seemed well to speak emphatically upon this 
point, inasmuch as the question is so frequently 
asked, and because some difference of opinion 
exists. 
Symptoms.-The symptoms of acute prostatitis 
are: A sensation of heat and of weight in the 
perineum or in the rectum; micturition is more 
frequent than normal and may be attended with 
tenesmus; if there is great swelling of the gland, 
retention may result; pain soon becomes a prom- 
inent symptom and is frequently very severe-it 
may be throbbing in character, it is worse on mo- 
tion, and the usual sitting position is uncomfortable 
if not impossible; a constipated stool is attended 
with very acute suffering; pressure on the perineum 
causes pain; digital examination of the prostate, 
per rectum, shows the gland to be somewhat en- 
larged and tense, and pressure causes very acute 
pain. There is always some constitutional dis- 
turbance in these cases; the temperature ranges 
from 100° to 103° F., and the pulse is proportion- 
ately accelerated. 
In the higher grade of inflammation pus is 
likely to form. The occurrence of suppuration is 
often announced by a chill, and digital examina- 
tion at this stage will sometimes reveal an area of 
softening at some point of the gland or distinct 
fluctuation may be felt. The abscess may remain 
localized until it is evacuated, it may discharge 
spontaneously, or the whole gland may break 
down rapidly. In connection with the last termi- 
Acute Prostatitis. PROSTATE GLAND, INFLAMMATION 
PROSTATE GLAND, INFLAMMATION 
nation the constitutional disturbance is usually 
pronounced. Septicemia and pyemia are rare 
terminations of acute prostatitis, and are especially 
liable to occur in the cases in which the peri- 
prostatic tissues are involved with secondary 
thrombosis of the prostatic plexus of veins. 
Diagnosis.-Acute prostatitis must be distin- 
guished from acute posterior urethritis; from acute 
cystitis, especially that form affecting chiefly the 
vesical neck; from cowperitis, and from stricture 
of the urethra and hypertrophy of the prostate. 
Acute posterior urethritis may present all the 
urinary symptoms observed in acute prostatitis; 
the constitutional symptoms, which are usually 
marked in the latter, will, however, be absent, or 
nearly so, in the former; swelling and tenderness 
of the prostate, as determined by rectal palpation, 
will be absent in urethritis. Acute cystitis would 
likewise cause no change in the prostate gland; the 
condition of the prostate is the chief distinguishing 
feature between these two diseases. Cowperitis 
would be detected by the presence of a slight, very 
tender swelling on one side of the perineum (unless 
the disease were bilateral); the absence of change 
in the prostate would exclude inflammation of this 
structure. 
Stricture of the urethra would not be accom- 
panied by the local evidences of inflammation of 
the prostate gland or the accompanying febrile 
symptoms. Hypertrophy of the prostate almost 
never occurs before the age of 50, and is not usually 
observed until the sixtieth year or later. The 
absence of acute inflammatory symptoms would 
exclude acute prostatitis. 
Treatment.-In common with all other acute in- 
flammatory processes the treatment of acute pros- 
tatitis should include absolute rest and a position 
that will favor emptying the part of blood as much 
as possible. Therefore, rest in bed-with the hips 
elevated upon pillows to a higher level than the 
shoulders-is to be insisted upon. In the more 
acute cases the local abstraction of blood by means 
of leeches applied to the perineum and around the 
margin of the anus will be followed by marked 
amelioration of the pain. Hot sitz-baths or hot 
compresses applied to the hypogastrium and 
perineum act beneficially by withdrawing the blood 
from the deeper parts to the surface. Hot-water 
clysters are likewise useful. 
If there is marked fever, a prescription similar to 
the following should be used: 
I|. Boric acid, 
Sodium bromid, 
Tincture of belladonna, 5 ss 
Solution of citrate of potas- 
sium, add enough to 
make 5 viij. 
One tablespoonful to be taken every 3 hours. 
If the pain is severe, 1 grain of morphin sulphate 
may be added to the foregoing mixture with ad- 
vantage, or suppositories may be administered. 
A common and useful formula for the latter is: 
1$. Extract of belladonna, gr. iij 
Watery extract of opium, gr. vj 
Cacao-butter, add enough to make 12 
suppositories. 
One of these may be introduced into the rec- 
tum 2 or 3 times a day, according to the 
severity of the pain. 
Straining, either at stool or during micturition, 
should be avoided, as it increases the congestion 
in and about the prostate and aggravates the 
symptoms. If the patient is unable to pass his 
urine naturally, it should be drawn, preferably 
with a Nelaton catheter of medium size (14 to 18 
of the French scale). The bowels should be kept 
acting rather freely by the use of salines or other 
laxatives. The diet should be restricted to milk 
as nearly as possible. Stimulants should not be 
given unless indicated by some other condition, 
and then in moderation only. 
If abscess of the prostate forms, the pus should 
be evacuated as soon as detected. The incision 
should be made through the perineum, except in 
those rare instances in which the pus appears just 
beneath the mucous membrane of the rectum, 
when the incision may be made in this situ- 
ation. To reach a collection in the prostate 
through the perineum, the index-finger of the left 
hand should be introduced into the rectum and the 
abscess located; then a straight bistoury, with the 
cutting-edge directed upward, is introduced into 
the perineal raphe, about 3/4 of an inch anterior 
to the anus, and carried forward toward the tip of 
the finger in the rectum until the abscess is reached. 
Neither the urethra nor the rectum should be 
wounded in this operation. The incision should 
be enlarged upward sufficiently to give free exit to 
the pus. It is always well to explore with the 
finger, to be certain that the drainage is free, and 
also to break up any partitions that may exist. 
Thorough irrigation with an antiseptic solution 
and moderate packing with iodoform gauze com- 
plete the operation. In the event of profuse 
hemorrhage following the operation, the packing 
should be firm. The gauze should first be removed 
on the second or third day, after thorough soaking 
with antiseptic solution. The dressings are to be 
repeated daily thereafter. Sometimes a urethro- 
perineal or a urethrorectal fistula will persist; 
but with proper attention to the care of the wound 
this will be rare. A prostatic abscess will usually 
be evacuated through the urethra, either spon- 
taneously or as the result of passing a catheter. 
This is to be considered a favorable termination, 
but in severe cases with marked local and con- 
each, gr. clx 
R. Boric acid, 
Potassium bromid, 
each, 5 j 
Potassium citrate, 3 ij 
Tincture of aconite, in Ixxij 
Tincture of belladonna, 5 ss 
Sweet spirit of niter, 5 ss 
Water, add enough to make, 5 vj. 
One tablespoonful every 3 hours. 
If pronounced vesical irritation is present, the 
administration of some such mixture as the fol- 
lowing will give marked relief: PROSTATE GLAND, INFLAMMATION 
PROSTATORRHEA 
stitutional symptoms it is not proper to depend 
upon this event, and in such cases there are no 
exceptions to the rule to evacuate a prostatic ab- 
scess by incision as soon as it is detected. 
Treatment.-No treatment is rational that 
does not begin by removing the cause of the 
trouble as far as possible. Therefore, any con- 
dition that tends to keep up a congestion of the 
prostate should be removed. Phimosis, stricture 
of the urethra, constipation, and undue sexual 
excitement are among the common causes that 
should be looked for, and, if present, they should 
receive appropriate attention. The application of 
a jet of cold water to the perineum and about the 
anus twice daily will act efficiently in causing a 
reflex contraction of the prostatic vessels. Coun- 
terirritation to the perineum is also useful. It may 
be secured by the daily application of equal parts 
of tincture of iodin and tincture of belladonna, 
until the skin becomes somewhat tender, when it 
should be discontinued for a few days. The effect 
of a few drops of nitrate of silver deposited in the 
prostatic urethra two or three times weekly, by 
means of a long-nozzle syringe, will be beneficial in 
many cases. It is well to begin with a solution 
of the strength of 1/2 of 1 percent, as stronger 
applications are followed by severe reaction; the 
strength may be gradually increased with ad- 
vantage. Massage of the prostate is probably the 
most efficient method of treatment at our com- 
mand. It has been much neglected, undoubtedly 
because of the unpleasant features both to the 
patient and the surgeon. In applying the treat- 
ment the patient may be placed either on his back 
or in the knee-elbow posture. To carry out 
digital massage, the middle finger should be in- 
troduced into the rectum, and the gland rubbed 
from left to right, and from right to left, pressure 
being made toward the symphysis. The seance 
may last 5 or 10 minutes, and may be repeated 
every day or second day. 
In addition the different functions of the body 
should receive careful attention. Tonics may be 
indicated, and the mental depression is most 
effectively treated by confidently reassuring the 
patient, and setting his mind straight, if he is 
laboring under mistaken ideas as to the source 
and significance of the different symptoms. 
PROSTATORRHEA.-A condition in which the 
prostatic fluid is discharged during defecation or 
after micturition, or independently thereof. 
Associated nervous or hypochondriacal symptoms 
are usually present. Prostatorrhea is due to 
relaxation of the prostatic ducts, which may 
depend upon chronic gonorrheal inflammation, 
sexual excesses or masturbation. This condition 
is often confounded with chronic prostatitis but 
the two are independent of each other, although 
they may be co-existent. There are many cases 
of prostatorrhea in which the secretion contains 
no pus, and, on the other hand, there are many 
cases of prostatitis in which no signs of prostator- 
rhea are present. Treatment consists in the employ- 
ment of local measures to relieve the congestion of 
the prostatic urethra and prostate gland. Chief 
among these may be mentioned the use of sounds, 
deep instillations of silver nitrate solution, and 
cool rectal douches. Attention to hygiene is im- 
portant, and as a rule tonics, such as arsenic, iron 
and the simple bitters, will prove of value. 
Chronic prostatitis is a more common affection 
than the acute variety, but as the symptoms are 
much less prominent, many cases never come to 
the attention of the practitioner. 
Etiology.-Chronic prostatitis either follows as 
a sequel to an acute inflammation of the gland, or 
it develops as a result of a long-continued or of 
frequently repeated prostatic congestion. Among 
the causes that induce chronic congestion in this 
region may be mentioned the prolonged use of 
irritating injections; excessive sexual excitement, 
however induced; hemorrhoids; exposure to cold; 
stricture of the urethra; vesical calculus; and 
injury with catheters and sounds. Probably the 
most common cause is gonorrheal infection. 
Symptoms.-Chronic prostatitis usually gives 
rise to dull pains, deep in the perineum, and to 
reflex pains in the thighs and sacral region. There 
may be some increase in the frequency of urination, 
and slight pain at the end of the act. The prostate, 
as felt through the rectum, may be of normal size 
or slightly enlarged; there is usually moderate sen- 
sitiveness to pressure. The urine may be slightly 
cloudy, due to the presence of mucus or mucopus 
and epithelium derived from the prostatic urethra. 
With the last drops of urine sand-like particles, 
composed of phosphate and carbonate of lime are 
often expelled. It is supposed that they are forced 
out of the prostatic ducts by contraction of the 
sphincter muscle. Another symptom to which 
Casper has called attention is the occurrence of 
residual urine in young men in whom no cause for 
its existence can be found. He thinks it is due to 
contraction of the sphincter, as the result of which 
the bladder cannot empty itself. There may be 
imperfect erections, premature ejaculations, or 
nocturnal emissions. Sexual intercourse and 
pollutions are often painful. In addition to these 
symptoms many nervous phenomena occur, but 
they undoubtedly owe their existence to a con- 
comitant neurosis rather than to the prostatitis. 
Diagnosis.-The symptoms of chronic prostatitis 
as outlined are fairly characteristic. The follow- 
ing procedure is a valuable aid in the diagnosis of 
doubtful cases: The patient is requested to pass an 
ounce or two of urine in one vessel and an equal 
or greater amount in a second, but still to retain 
a portion of urine in the bladder. The prostate is 
then thoroughly expressed by massage from the 
rectum, either by the finger or with an instrument 
specially designed for the purpose; finally, the 
patient passes the last portion of urine. If chronic 
inflammation of the prostate exists, the last urine 
will contain shreds of mucus, pus, and epithelium, 
forced into the urethra from the prostatic glands 
by the massage. In applying this test care must 
be observed not to mistake chronic seminal vesi- 
culitis for prostatitis. The distinction will be 
made by avoiding the seminal vesicles when 
massaging the prostate. 
Chronic Prostatitis. PROSTRATION 
PRURITUS 
PROSTRATION.-See Collapse, Exhaustion, 
Neurasthenia, Shock. 
PROTARGOL.-A proteid compound of silver 
containing 8 percent of the metal. It has many 
strong advocates as a substitute for silver nitrate. 
It is not so painful, is more germicidal, has greater 
penetrating powers, and does not form a pre- 
cipitate with albumin. It has been used in all 
forms of conjunctivitis in strengths of from 2 
percent to 50 percent. A 2 percent solution is 
generally used as a collyrium. Recently, there 
has been considerable dissent from the numerous 
favorable reports, and there has been an inclina- 
tion to restrict its use to the milder inflammations 
of the conjunctiva. 
PROTOZOA.-Unicellular organisms repre- 
senting the lowest type of animal life. Of those 
that are parasitic in man the most important are: 
(1) The rhizopoda which include the ameba coli, 
the cause of amebic dysentery; (2) the flagellata, 
to which class belong the trichomonas, found most 
frequently in the vagina but also in the digestive 
tract and occasionally in the lungs, and the 
trypanosomes (see Sleeping-sickness); (3) the 
sporozoa which include the coccidia, and also 
the hemosporidia (to which belong the plas- 
modia of malaria). The spirocheta pallida of 
syphilis is believed to belong to the protozoa. 
It has been affirmed that molluscum contagiosum 
and carcinoma are due to protozoa, the cancer 
cells and the molluscum bodies being regarded as 
parasites. Smallpox is probably caused by a 
protozoon. 
PRUNUS VIRGINIANA (Wild Cherry).-The 
bark of P. serotina. It contains tannin, gallic 
acid, resin, starch, etc., also amygdalin and emulsin, 
which by their mutual reaction in the presence of 
water, produce hydrocyanic acid and a volatile oil 
resembling that of bitter almond. The root-bark 
contains a glucosid, phloridzin, found also in the 
same part of the apple, pear and plum trees. 
Wild cherry is aromatic and feebly tonic; it is 
largely used in pulmonary tuberculosis to quiet 
the cough and to calm the nervous system; also in 
coughs of bronchitis. It is an ingredient of 
various proprietary cough mixtures. Dose of 
the bark, 20 to 45 grains; of the fluidextract, 
20 to 40 minims; of a 4 percent infusion, 1/2 to 3 
ounces; of a 15 percent syrup, 1/2 to 1 1/2 drams. 
PRURIGO.-Prurigo is an inflammatory disease 
of the skin, characterized by the occurrence of 
pale red papules, from the size of a pinhead to 
that of a lentil seed, occurring chiefly upon the 
extensor surfaces of the extremities, beginning in 
infancy or early childhood, lasting for years or 
throughout a lifetime, and accompanied by 
intense itching. 
Symptoms.-According to the severity of the 
disease, two types are distinguished-prurigo 
ferox (severe prurigo) and prurigo mitis (mild 
prurigo). 
The disease usually begins in the first year of 
life, not infrequently taking the form of an ordi- 
nary urticaria. Later there appear upon the ex- 
tensor surfaces of the legs and arms, the trunk, 
and sometimes the forehead, pinhead-sized or 
larger discrete, firm papules. These may be pale 
red or may have the natural color of the skin. 
The itching is intense, as a result of which the 
affected areas are covered with excoriations and 
blood crusts. After a time the skin becomes 
harsh, dry, greatly thickened, and sometimes 
pigmented. The neighboring lymphatic glands, 
particularly those in the inguinal regions, are 
often so greatly enlarged as to be apparent to the 
eye. 
The disease is extremely rebellious, and may 
persist for years, or even throughout the entire 
lifetime of the individual. It is apt to undergo 
spontaneous improvement in the summer season. 
Prurigo is distinctly rare, particularly in this 
country. 
Etiology and Pathology.-The disease is en- 
gendered by the environment of "misery," poor 
food, bad hygiene, etc. The pathology does not 
differ markedly from that of the chronic papular 
eczema. 
Diagnosis.-The localization and character of 
the papules, the thickened skin, the marked 
adenopathy, the chronic course, and the history 
of the disease render its diagnosis easy. 
Prognosis.-Severe cases often persist for a 
lifetime. Milder cases may, under judicious 
treatment, be cured. Some cases recover spon- 
taneously at about the age of puberty. 
Treatment.-The therapeutic indications are to 
relieve the intense itching, to get rid of the erup- 
tion, and to improve the general health. Nutri- 
tious food and proper hygiene are essentials. 
Tonics, such as iron, cod-liver oil, and the hypo- 
phosphites, are often indicated. Crocker recom- 
mends for the relief of itching the tincture of 
cannabis indica, beginning with 5-minim doses- 
in a child of 8, for instance-and increasing to 
the physiologic limit. 
Locally, ointments of beta-naphthol, sulphur 
(1 dram to the ounce), and tar are of value. 
Kaposi strongly advocates the following: 
1$. Beta-naphthol, gr. x to xxx 
Petrolatum, 3 j. 
Rub in each night. 
Baths are extremely useful, particularly the 
alkaline bath (sodium carbonate, 4 ounces to 
30 gallons of water) and the sulphur bath (pre- 
cipitated sulphur or potassium sulphid, 4 ounces 
to 30 gallons of water). 
PRURITUS.-Pruritus is a functional cutaneous 
disorder characterized by itching, without struc- 
tural alteration of the skin. 
Symptoms.-Itching is the sole symptom-it 
may be of a tickling, pricking, crawling, or tingling 
character. The patient is invariably prompted to 
scratch and rub the affected part. As a result of 
long-continued scratching, excoriations, papules, 
and thickening of the skin may result. The 
itching is paroxysmal, and nearly always worse at 
night. 
Pruritus may be general (pruritus universalis) or 
local (pruritus localis). The regions commonly 
attacked in the latter variety are the anus (pru- PRUSSIC ACID 
PSOAS ABSCESS 
ritus ani), the vulva (pruritus vulva), and the 
scrotum (pruritus scroti). 
Pruritus is far more common in advanced life 
(pruritus senilis). 
The form of pruritus occurring during the cold 
months of the year is designated pruritus hiemalis. 
Etiology.-Generalized pruritus may be caused 
by Bright's disease, diabetes, hepatic affections, 
digestive and intestinal disturbances, nervous 
disorders, pregnancy, uterine and ovarian disease, 
ingestion of certain medicaments, etc. 
Pruritus vulvae is not infrequently produced by 
irritating vaginal discharges. It is a common 
symptom in diabetes. Pruritus ani may be caused 
by hemorrhoids, fissures, seat-worms, etc., or may 
be due to digestional disorders, gout, or some 
other constitutional condition. 
Diagnosis.-Pediculosis corporis may usually be 
differentiated from pruritus by the localization of 
the scratch marks and the presence of the para- 
sites in the garments. 
Prognosis.-Guarded. Depends upon the nature 
and removability of the cause. 
Treatment.-The cause must be assiduously 
investigated and treated. 
Internal Treatment.-Diet and hygiene should 
be carefully regulated. The various visceral dis- 
eases must receive appropriate treatment. In 
obscure cases the mineral acids, quinin, strychnin, 
atropin, gelsemium, pilocarpin, and arsenic may 
be variously tested. 
Local treatment is designed to give merely 
temporary relief from the distressing itching. 
The following are some of the best antipruritic 
lotions: 
B. Phenol, 3 j to iij 
Glycerin, 5 ij 
Alcohol, 3 iv 
Water, add enough to make O j. 
B- Liquor carbonis detergens, 3 ss to ij 
Water, Oj. 
1$. Thymol, 3 ss to ij 
Solution of potassa, 3 ij 
Glycerin, 3 ss 
Water, O j. 
For pruritus vulvae one may use: (1) Saturated 
solution of boric acid; (2) compound tincture of 
benzoin (painted on); (3) vaginal injections of 
alum, zinc sulphate, etc. 
For pruritus ani: 
B- Phenol, gr. x to xx 
Calomel, gr. xx to xxx 
Zinc oxid ointment, 3 j. 
B. Mercuric chlorid, gr. viij to xvj 
Water, 3 viij. 
3. Morphin sulphate, gr. x 
Flexible collodion, 3 j. 
See Anus, Vulva. 
PRUSSIC ACID.-See Cyanids. 
PSAMMOMA (Sand Tumor).-A fibrosarcoma, 
containing calcareous material, observed rarely in 
the meninges, pineal gland and choroid plexus. 
PSEUDOCYESIS (False Pregnancy).-The be- 
lief in the existence of pregnancy on the part of a 
woman, accompanied, perhaps, by more or less 
vague subjective signs. This condition occurs in 
nervous, hysteric women as a rule. It is seen 
most frequently in unmarried girls who fear the 
results of illicit sexual connection, or in sterile 
married women who are approaching the meno- 
pause and who very much desire offspring. 
It is accompanied usually by such common 
symptoms of pregnancy as nausea, enlargement 
of the abdomen, and sometimes cessation of men- 
struation. A careful vaginal examination (pre- 
ferably with the aid of anesthesia), will reveal 
an absence of the characteristic signs of true 
pregnancy. 
Treatment should be directed toward the general 
nervous condition. Sedatives, tonics, and change 
of food, air, and scene will be found most bene- 
ficial. 
PSEUDOLALIA.-See Speech Defects. 
PSEUDOLEUKEMIA.-See Lymphadenoma. 
PSEUDOLEUKEMIA, SPLENIC.-See Splenic 
Anemia. 
PSEUDOLEUKEMIC ANEMIA OF INFANCY.- 
A chronic anemia of infants and young children 
described by von Jaksch, characterized by marked 
leukocytosis and marked reduction in the red 
cells and hemoglobin, greatly enlarged spleen, 
sometimes moderately enlarged liver with sharp 
edges and at times enlarged lymphatic glands. 
The disease is not to be confounded with pseudo- 
leukemia, in which there is no leukocytosis, nor 
with leukemia, in which there is not so marked a 
reduction of hemoglobin or in the number of red 
cells but a greater increase in the number of 
leukocytes. The leukocytes are characterized by 
their varied shape and unusual size. The red cells 
display a high degree of poikilocytosis, while white 
cells inclosing red cells and fragments of red cells 
are also found, together with occasional eosino- 
philic leukocytes and large multinuclear neutro- 
philic leukocytes and nucleated red cells. All of 
these modifications of the blood-corpuscles, how- 
ever, may occur in leukemia. Prognosis is only 
guardedly favorable, for death often occurs from 
intercurrent disease. 
PSILOSIS.-See Sprue. 
PSOAS ABSCESS.-Chronic collections of tuber- 
culous fluid, which form in the cellular substance of 
the loins, behind the peritoneum, and descend in 
the course of the psoas muscle; if the disease forms 
on the side of the vertebrae, instead of the fore 
part, it is termed lumbar abscess. 
Etiology.-This disease arises generally from 
cold, strains, or falls, and from general debility, 
and not infrequently from spinal affections. 
Symptoms.-At the beginning there is little or no 
pain, no inflammation, nor is there febrile dis- 
turbance; but previous to the appearance of any 
other symptom the patient has' an unaccountable 
feeling of weakness across the loins, accompanied 
by pains, usually giving no indication of the seat 
of the disease, and likely to be regarded as rheu- 
matic. The tuberculous fluid is formed slowly and 
imperceptibly, and occasions, at first, no manifest PSORIASIS 
PSORIASIS 
swelling or fluctuation. When the lower dorsal 
or upper lumbar vertebrae are diseased, the pus 
enters the sheath of the psoas, or the substance of 
the muscle, and is firmly bound down in front by 
the fascia covering this muscle and the iliacus. 
The abscess proceeds as far as the tendon of the 
muscle by Poupart's ligament, where its further 
progress will probably be arrested. When it has 
attained considerable magnitude, it passes under 
Poupart's ligament, between the femoral vein and 
the symphysis pubis. 
The diagnosis is difficult when the abscess is 
unattended by an external tumor. The swelling 
takes place in various situations and assumes 
different aspects; it may appear beneath the fem- 
oral fascia, or it may descend as far as the knee 
and form a prominent swelling; sometimes it will 
make its way downward into the pelvis and occa- 
sion a swelling in the neighborhood of the anus, or it 
may appear in the vicinity of the vertebrae, or, 
again, it may make its may through the abdom- 
inal muscles. 
Treatment.-A psoas abscess should be opened, 
if possible, before it leaves the abdomen, just 
about Poupart's ligament, external to the line of 
the vessels. If it points at the inner side of the 
thigh, an incision may be made in that situation, 
in addition to the one above Poupart's ligament. 
Under antiseptic precautions, the sooner the ab- 
scess is opened, the better, for the abscess cavity 
is then smaller than if the surgeon waits until the 
fluid has burrowed its way into the thigh. Free 
drainage should be established from the groin to 
the lumbar region. The same principal of treat- 
ment must be applied to lumbar abscesses. Anti- 
septic dressings must be continued as long as there 
is discharge. General tonic and alterative treat- 
ment is indicated. See also Spine (Caries). 
PSORIASIS.-A common chronic inflammatory 
disease of the skin, characterized by variously 
sized lesions, having red bases, covered with white 
scales resembling mother-of-pearl. It affects by 
preference the extensor surfaces of the body. 
The lesions are infiltrated, elevated, clearly defined, 
covered with white, shining, easily detachable 
scales which, upon removal, reveal a red, punc- 
tate, bleeding surface. The eruption is absolutely 
dry, and itching is usually absent. The recog- 
nition of psoriasis depends upon a clear compre- 
hension of the many manifestations exhibited by 
this cutaneous affection. The lesions observed in 
the early stages of an attack may not always be 
sufficiently distinct to the casual observer to 
obviate error. Those noted in the later periods 
of the condition are usually characteristic. 
Symptoms.-Early in its inception psoriasis is 
observed to present lesions of a papular nature and 
of diminutive size. Scattered here and there over 
the body surface there are noted pinhead-sized or 
smaller lesions, each of which very early in its 
life becomes tipped with a minute scale of a pearly 
white color. They are slightly raised above the 
surrounding healthy skin, and while showing a 
pinkish-red coloration directly at the point of 
attack, the amount of inflammation is not of a 
high grade, and does not extend beyond the borders 
of the individual papule. Enlarging by gradual 
peripheral extension-either slowly or quickly- 
they soon become easily discernible and charac- 
teristic. 
Later in their course they have been known to 
attain varying dimensions-from the diminutive 
lesion to those occupying areas one inch or more in 
diameter, or when two or more in close proximity 
have coalesced, forming patches the size of one's 
hand, or even covering the greater part of one limb, 
or occasionally the major part of the back or chest. 
The edges of these lesions are distinct and stand 
out prominently, being, with the entire patch, 
raised somewhat above the surrounding areas. 
They are always dry and covered with abundant, 
pearly white, shining scales, which are arranged 
one upon the other in an imbricated manner. The 
removal of the scale often presents some bleeding 
points upon the affected areas. The patches often 
assume grotesque outlines-being in some in- 
stances annular or circinate, and in still others 
semicircular or arranged in bands-to each of 
which descriptive names are applied. Although 
rarely giving sensitive impression of their existence, 
they occasionally give rise to intolerable itching in 
certain nervous constitutions. 
Psoriasis may remain stationary at any stage of 
its process, but, generally seen, all stages may be 
depicted in any given case. While the affection 
may be observed at any point of the body surface, 
it usually accepts certain points, such as the scalp, 
elbows, and knees, as its most formidable positions. 
It may be observed at any age, although early 
adult life presents the greater number. 
Diagnosis.-The special points of value in refer- 
ence to diagnosis are: Lesions of variable dimen- 
sions, all being capped with the pearly white scales; 
borders severely outlined; tendency to coalescence, 
with the presentation of bleeding points upon 
removal of scale. 
In differentiating psoriasis from eczema care 
should be exerted to observe the dry character of 
lesions which are scattered over the entire body 
surface; their tendency to coalescence, with the 
appearance of characteristic scale; the chronic 
course, with existence of but slight, if any, itching; 
the well-marked borders and regularly rounded 
outline of each lesion. In eczema there is always 
a history of moisture, with occasionally crusting 
and scaling; the patches always fade into surround- 
ing areas, and are continually changing; itching is 
usually severe, while the inflammation is more of 
an acute nature. 
In contradistinction to syphilis, psoriasis gives 
no history of initial lesion; there is no enlargement 
of glandular structures; lesions are symmetric, pre- 
sent a tendency to uniformity and coalescence, 
with abundance of pearly white scaling. Itching 
is occasionally present, although of but slight 
degree. Syphilis presents a history of contami- 
nation, with enlargement of cervical, inguinal, and 
epitrochlear glands. The lesions are asymmetric 
and multiform, but retain their contour. Itching 
is not a usual accompaniment. The scale is of a 
grayish tint. 
Erythematous lupus is more often limited to the PSORIASIS 
PSYCHOSIS POLYNEURITICA 
face and neck. The lesions number but two or 
three, are paler in tint, and covered with a fine 
yellowish or grayish scale; the center is depressed 
beneath the surrounding edge of the patch, and is 
more whitish in appearance than surrounding 
healthy areas. Upon removal of the scale, small 
sebaceous plugs may be observed emerging from 
the follicles. 
Tinea circinata rarely occurs over a great surface. 
It is an acute affection, and gives a history of con- 
tagion. Lesions are usually annular, and extend 
upon the periphery while the center is healing. 
Vesicles may often be noted upon their periphery. 
Psoriasis, while clearing in the center, presents a 
tendency to peripheral disappearance. 
Treatment.-While internal and external meas- 
ures may both be demanded in most of the cases 
of this affection, there are many in which either 
plan may prove Curative, and therefore it is 
advisable to acquaint one's self with the thera- 
peutic agents of both classes. 
Internal Treatment.-By far the greatest benefit 
may be received from the use of arsenic in one of 
its many forms; and while it has been supposed to 
possess specific properties for the removal of this 
affection, this cannot be proved, on account of its 
many failures. In the choice of this remedy it is 
advisable to select those cases in which there is not 
decided inflammation, as is often encountered in 
its early history, or those more chronic, wherein the 
drug has not been used. Arsenic seems to lose its 
power over the affection when used continuously 
or when repeated attacks are placed under its 
influence. One of the following plans may often 
prove beneficial: In one set of cases the best 
results follow the administration of 4 or 5 drops of 
the solution of arsenite of potassium, given 3 times 
daily for an indefinite period (arsenous acid, in 
doses of 1/20 grain, possesses a similar property). 
In another set of cases it may be found advanta- 
geous to increase the dose by 1 drop daily until 
near a point of tolerance, but not reaching that 
point. 
Cod-liver oil is efficacious in cases of lowered 
vitality, and is best administered in the maximum 
dose, according to the age of the affected individ- 
ual. The oil of copaiba, in doses of from 5 to 30 
drops, thrice daily, may be most judiciously 
advised in many cases of long standing or when the 
degree of inflammation is high. Potassium iodid, 
in 5-grain or 10-grain doses, given for indefinite 
period; the salicylates, in similar dosage, produce 
good effects. Iron and strong tonics are de- 
manded in certain depressed constitutions. Nu- 
merous other drugs are omitted, owing to the 
many chances of failure following their use. 
Sea-water injections are said to have been used 
with some success. 
External Treatment.-The first essential point 
in the external treatment is the removal of the 
scales; and to accomplish this, recourse must be 
had to the use of either baths or emollients. The 
ordinary bicarbonate of sodium or, preferably, the 
carbonate of potassium may be used in strengths 
varying from 1 to 3 ounces to each bath of 30 
gallons. Olive oil or liquid petrolatum may 
produce a similar effect, possibly without fear of 
irritation in injudicious subjects. 
Ordinary soap and water, applied thoroughly 
by means of a coarse towel, may likewise remove 
the abundance of scales, and thus present a clear 
base upon which to apply the chosen unguent. 
It may be found advisable to apply one of these 
measures frequently during the treatment of a 
case, owing to the tendency to reaccumulation 
of scales. 
Ointments or pigments may possibly be the 
preferable plan of using external drugs, although 
liquid applications may give as good results. 
Salicylic acid, in from 3 to 10 percent ointments, 
with petrolatum applied twice daily, may be satis- 
factorily borne by many patients, but care must 
be exerted not to produce too much irritation 
of the underlying skin or contiguous parts. Tar- 
in the form of the oil of cade, oil of birch, or ordi- 
nary liquid tar-in the proportion of 1 or 2 drams 
to the ounce of ointment, may be judiciously 
advised in many long-standing cases. Ichthyol 
proves beneficial in many instances, and may be 
used in strengths varying from 1 to 3 drams to 
the ounce, and applied once daily during the 
whole course of the disease. This class of remedies 
may also be used in watery solutions, in strengths 
similar to those mentioned. 
Chrysarobin produces excellent results in oint- 
ment form, in the strength of from 10 to 60 grains 
to the ounce of petrolatum, in those cases wherein 
much thickening has been induced by the process. 
It may also produce good effects when applied 
dissolved in the strength of from 10 to 60 grains 
to the ounce of either traumaticin or chloroform. 
Either of these plans will demand careful atten- 
tion, owing to the inflammation that may be 
induced; and if applied near the eye, violent iritis 
may follow. 
Pyrogallic acid may be used advantageously in 
a manner similar to the foregoing, and with less 
likelihood of producing ill effects. When psori- 
asis is observed upon the face or upon other visible 
parts of the body surface, it should be treated by 
some form of inunction, such as by ammoniated 
mercury, that does not give evidence of its pres- 
ence. This remedy, used in the strength of from 
10 to 40 grains to the ounce of petrolatum, will 
usually suffice. 
PSOROSPERMIASIS.-Psorosperms (sporozoa, 
cytozoa) belong to the lowest forms of the pro- 
tozoa. The most important psorosperms are the 
coccidium cuniculi and the coccidium hominis. 
The latter is reported to have caused a few cases 
of intestinal disease in man. The former has 
been found in man usually in the liver. Its 
presence gives rise to inflammation of the ducts 
followed by the formation of tumor-like nodules 
with a cheesy center containing pus, debris, coc- 
cidia and shed epithelial cells. These nodules 
with the massing of epithelial cells have led to the 
opinion that they are associated with cancer for- 
mations. The cutaneous lesions that sometimes 
occur simulate verrucose tuberculosis, mycosis 
fungoides or carcinoma. 
PSYCHOSIS POLYNEURITICA (Korsakow's PTERYGIUM 
PTOMAIN-POISONING 
Psychosis, Polyneuritis).-See Multiple Neuritis. 
PTERYGIUM.-A triangular patch of thick- 
ened conjunctiva, most common on the nasal side; 
the apex of the growth points toward the pupil, 
and the fan-shaped base radiates toward the 
canthus. As it continues to grow it resembles a 
mass of flesh; and as years go on it partly atro- 
phies, becomes pale, and appears tendinous. 
It is loosely attached at the limbus, and in this 
position a probe can be passed under its edges. 
On the cornea the growth is firmly adherent and 
must be torn or dissected away. If the ptery- 
gium grows over the cornea, it may drag the 
conjunctiva and caruncle with it to such a degree 
as to interfere with the movements of the eyeball, 
besides becoming unsightly. This affection is 
frequently found in elderly persons who have 
endured exposure in years of outdoor occupation. 
It is common in sailors. One eye is usually 
affected, although the growth has been seen sim- 
ultaneously in both eyes, and in rare instances 
has developed from the outer canthus. 
the ocular movements. Electrolysis is the most 
recent treatment proposed. 
PTOMAIN.-A basic nitrogenous compound, 
resembling the alkaloids, and produced by the 
action of bacteria on organic matter. As they are 
usually formed in putrefactive processes, ptomains 
have also been termed putrefactive alkaloids. 
The name cadaveric alkaloids has also been given 
to them, but applies properly only to those ob- 
tained from the dead animal body. Some of the 
ptomains are poisonous; many are not. As a 
rule, each distinctive ptomain is produced by a 
different microorganism, but there are instances 
of several bacteria producing the same ptomain. 
The dependence of a ptomain upon microorgan- 
isms may be indirect and comphcated by or de- 
pendent upon purely chemic changes. The kind 
of ptomain produced depends somewhat upon the 
stage of putrefaction, as ptomains are "transition 
products in the process of putrefaction." Their 
production is also influenced by the media in 
which the bacteria grow. A ptomain that is 
formed by a certain bacterium in one medium 
may not be produced by the same bacterium in 
another medium. Ptomains have been found in 
foods, as in mussels, oysters, eels, sausage, ham, 
canned meats, cheese, milk, ice cream, etc. The 
pathogenic action of certain bacteria may be due 
to their production of ptomains. In addition 
to the well-known ptomains, a number of un- 
named substances have been studied that possess 
reactions and physiologic effects similar to or iden- 
tical with those of well-known vegetable alkaloids. 
These at present can only be called after analogs 
-e. g., coniin-like substances; others are called 
atropin-like, delphinin-like, digitalin-like, mor- 
phin-like, nicotin-like, strychnin-like, veratrin- 
like, etc. See Leukomain, Ptomain-poisoning. 
PTOMAIN-POISONING.-Infection of the or- 
ganism through the medium of the gastrointestinal 
tract. 
Etiology. Exciting Causes.-Certain varieties of 
food which have partially undergone putrefaction, 
such as oysters, ice-cream (made of milk containing 
tyrotoxicon), sausage, meat, mussels, fish, and 
cheese. Sausage poisoning is not uncommon in 
Germany. Ham poisoning not due to trichina has 
been reported, and many cases of poisoning from 
canned meats are recorded, though these may be 
due to the chlorids of lead or tin. Milk, cheese, 
and ice-cream poisonings are not rare, although 
tyrotoxicon is not always the active cause. The 
mussel furnishes the most frequent source of 
poisoning from the shell-fish. See Ptomain. 
These foods contain a variety of poisonous 
ptomains after decomposition, such as tyrotoxicon 
(in milk), neurin, mydatoxin, methyl-guanidin (in 
meats), mytilotoxin (in mussels), and a poisonous 
base in fish isomeric with ethylidene diamin 
(C2H4(NH2)2). 
Predisposing Causes.-(1) A catarrhal condition 
of the stomach and intestines; (2) dilatation of the 
stomach; (3) certain diseases, as typhoid fever, 
enteritis, peritonitis; (4) idiosyncrasy toward 
certain kinds of food. 
Pathology.-In a case of ptcmain-poisoning 
Pterygium. 
Treatment.-If the growth has not extended 
upon the cornea and shows no sign of progression, 
it may be left undisturbed. A flat, stringy head 
indicates a cessation of growth, and excision need 
not be resorted to. A vascular head means active 
progression. The operation of removal is as 
follows: Grasp the neck of the pterygium with 
fixation forceps, making traction perpendicular 
to the surface; dissect up the head, and make 
two converging incisions into the body with a 
pair of scissors. The parts between these incisions 
are dissected away and the lozenge-shaped wound 
closed by a suture applied about the middle of 
the wound. Another method of removal is by 
transplantation. The growth is split longitudi- 
nally and is fixed in an upper and a lower con- 
junctival pocket with a suture. Ligation has also 
been recommended; a large part of the pterygium 
between the sclerocorneal margin and the base 
of the growth is strangulated by sutures in the 
manner shown in the illustration. It has been 
suggested that the whole trouble in pterygium 
lies in the apex, and curetting the affected cornea 
or the application of the galvanocautery has 
produced good results. Under the old opera- 
tions pterygium was liable to occur, and some- 
times repeated operations caused limitation of PTOMAIN-POISONING 
PTOMAIN-POISONING 
from milk observed by Vaughan and Prescott, 
the following lesions were found 15 hours after 
death: "The mucous membrane of stomach and 
intestines normal (bile-stained); the small intestine 
distended with gas; the jejunum ashy green in 
color; the ileum purplish green; the cecum, 
ascending, transverse, and descending colon empty; 
the circular fibers tightly constricted; the salivary 
glands distinct but not inflamed; Peyer's patches 
normal; the liver and spleen normal." Rigor 
mortis is usually quite marked. 
In other cases of ptomain-poisoning the mucous 
membrane of the stomach and intestines has been 
found red and swollen, presenting the picture of 
acute inflammation; the large vessels filled with 
dark blood; the kidneys congested; spleen enlarged; 
the heart either empty or filled with dark blood. 
It would seem, therefore, that the materies 
morbi, while primarily acting as a gastrointestinal 
irritant, after being absorbed spends its force 
chiefly upon the nervous system. 
Symptoms and Clinical Course.-The symptoms 
of ptomain-poisoning usually manifest themselves 
in from 2 to 24 hours after the food has been taken. 
Nervous Symptoms.-Sense of chilliness, cold- 
ness of extremities, headache, vertigo, dryness of 
mouth, extreme thirst, constriction of the throat, 
difficult deglutition, intense pains in the abdominal 
region and calves of legs, muscular weakness, 
twitching of eyelids and muscles of face, shoulders, 
and hands, tingling sensations, hallucinations, 
mental anxiety, imperfect vision, dilatation of 
pupils, strabismus, dyspnea, convulsions, and 
coma. 
Gastrointestinal Symptoms.-Abdomen re- 
tracted, sense of heat in stomach, excessive nausea, 
persistent vomiting, usually watery diarrhea. 
Constipation is present in some instances. 
Cutaneous Symptoms.-Scarlatinal rash, urti- 
caria. 
Circulatory Symptoms.-Heart feeble and quick, 
often 140 to a minute; violent throbbing of ab- 
dominal aorta. 
Temperature.-In many cases there is a sub- 
normal temperature (95° F.), but if the case is 
protracted, the temperature is somewhat elevated 
(100° to 102° F.). 
Respirations are hurried (dyspnea), 35 to 40 a 
minute. 
Diagnosis.- 
Acute Gastroin- 
testinal. Autoin- 
toxication. 
Cholera Morbus. 
Mineral Poison. 
4. Early dyspnea, 
cyanosis. 
5. Temperature of- 
ten subnormal. 
6. Dryness of mouth 
and fauces, often 
bitter taste. 
7. Vomitus contains 
mucus, contents of 
stomach, or bile. 
8. Generally watery 
diarrhea, some- 
times constipation. 
9. Various cutaneous 
eruptions (scarla- 
tinal eruptions, ur- 
ticaria) . 
4. Respirations nor- 
mal. 
5. Temperature of- 
ten elevated a de- 
gree or two. 
6. Bitter or sour 
taste in mouth. 
7. Vomitus has a 
sour or bitter taste 
without blood. 
8. Diarrhea and 
tenesmus; feces 
greenish in color. 
9. Cutaneous erup- 
tions absent. 
4. Dyspnea comes 
on late in mineral 
poisoning. 
5. Temperature of- 
ten elevated a de- 
gree or two. 
6. Metallic taste in 
mouth. 
7. Vomitus varia- 
ble, often tinged 
with blood, and 
containing trace 
of poison. 
8. Feces may con- 
tain blood and 
trace of poison. 
9. Cutaneous erup- 
tions absent. 
Prognosis is guardedly favorable. 
Treatment.-After the diagnosis has been fully 
determined, the first attempt should be directed 
toward the removal of the cause of the evil by aid 
of the stomach-tube, emetics (if needed), irrigation 
of the bowel with long rectal tube attached to a 
fountain syringe; and, subsequently, remedies to 
control the pain, to combat the symptoms of 
shock, and intestinal antiseptics to keep down 
intestinal putrefaction. 
The stomach-tube may be introduced at once, 
and 11/2 pints of lukewarm water allowed to run 
in; the funnel of the tube should then be lowered 
and the fluid drained away. The process may be 
repeated until the stomach is thoroughly cleansed. 
See Lavage. 
The rectal tube is then inserted into the bowel its 
full length and attached to a fountain syringe, and 
from 1 to 2 quarts of lukewarm water introduced. 
After the fluid has been expelled, the operation 
may again be repeated. 
If emesis is not sufficient to expel the gastric 
contents and time is lost in procuring a stomach- 
tube, apomorphin (1/4 of a grain) may be given 
hypodermically. Should the bowels be consti- 
pated and the stomach retentive, magnesium 
sulphate (6 drams), Rochelle salt (6 drams), or 
solution of citrate of magnesia (10 ounces) may be 
given at once. Pain is best relieved by morphin 
(1/4 of a grain) hypodermically. 
If collapse threatens, it must be combated with 
hypodermics of atropin (1/100 grain), strychnin 
(1/30 grain), nitroglycerin (1/75 grain), whisky, 
inhalations of ammonia, nitrite of amyl, and hot 
applications to abdomen and extremities. After 
the stomach and bowels have been thoroughly 
cleansed by means of irrigation and purgatives, the 
following prescription may be given: 
Acute Gastroin- 
testinal Autoin- 
toxication. 
Cholera Morbus. 
Mineral Poison. 
1. Onset often from 
1. Onset usually at 
1. Onset within half 
2 to 24 hours. 
night or early 
morning hours. 
an hour. 
2. Results from eat- 
ing animal (nitro- 
genous) food. 
2. Results from eat- 
ing fruits or vege- 
table food. 
2. History negative 
3. Nervous symp- 
3. Nervous phenom- 
3. Nervousphenom- 
toms marked 
ena, as seen in 
ena, as seen in 
(twitching of facial 
autointoxicati o n, 
autointoxicat ion, 
muscles, tingling 
sensations, dilated 
pupils, c o n v u 1- 
sions). 
absent. 
absent. 
I). Codein, gr. iij 
Naphthalin, 
Bismuth subnitrate, 
each, 3j. 
Divide into 8 powders. One powder every 2 
hours. 
Naphthalin (10 grains) or naphthol (4 grains) PTOSIS 
may be given every 4 hours for 2 or 3 days. Salol 
(5 grains) may be substituted for the other intes- 
tinal antiseptics. 
PTOSIS.-Drooping of the upper eyelid. It 
may result from any effusion or inflammation 
weighing down the upper lid. Excessive deposits 
of fat in the lid may cause it to droop. Ptosis also 
results from injury to or paralysis of the levator 
palpebrae muscle. It is one of the symptoms of 
palsy of the third nerve. 
The treatment of ptosis consists in removing the 
cause if possible. In paralysis of the levator 
muscle strychnin and the galvanic current are use- 
ful. Several ingenious lid elevators have been 
devised for the relief of this condition. Operative 
interference has for its object the removal of a 
piece of the skin of the upper lid, or the insertion 
of silver wire to hold the lid up. The tendon of the 
levator muscle may be advanced, or the tarsus 
may be sutured to the temporal muscle. The 
patient can often relieve ptosis by learning to use 
the temporal muscle, or by throwing the head 
backward in order to see better. 
A simple and effective operation for ptosis con- 
sists in passing a stout silk ligature vertically under 
the skin from the eyebrows to the margin of the 
lids, and firmly tying the ends. The noose formed 
in this manner is tightened every day, until it has 
cut its way through the confined tissues; the 
resultant cicatrix draws the lid to its normal 
position. 
PTYALAGOGS.-See Sialagogs. 
PTYALISM.-See Mercury (Salivation). 
PUBERTY.-1. The period at which the genera- 
tive organs of the male or the female become cap- 
able of exercising the function of reproduction. 
2. The changes in the generative organs and in the 
general system that accompany the inauguration 
of this period. 
Puberty occurs earlier in warm climates, in 
sanguine temperaments, and in highly cultivated 
and luxurious states of society. It cannot* be 
estimated by age alone, and it is modified by 
family or hereditary peculiarities and the in- 
fluence of various diseases. In the male the voice 
becomes bass, while about the same time hair 
grows on the face, pubes, and other parts of the 
body. Before this the male genital organs 
develop; the testes enlarge, as do other parts of the 
sexual apparatus; seminal and other accessory 
fluids are secreted, and there is an out-burst of 
sexual feelings and instincts. The changes are 
so slowly proceeding that they are not completed 
until full age has been passed. 
In the female the individual passes from child- 
hood to womanhood. The external genital organs 
enlarge, the uterus, ovaries, and breasts develop, 
and the commencement of the periodic menstrual 
discharge is marked. This time is usually, in this 
climate, between 13 and 15 years. The nonap- 
pearance of menstruation may be due to some 
constitutional disease or some general condition, 
the rational treatment of which rather than any 
uteroovarian stimulation should receive the 
physician's attention. Many of the ailments 
common about the period of puberty are but 
forerunners and accompaniments of the functional 
and organic changes about to commence, especially 
in the female sex. The influence of excessive 
mental stimulation during puberty is a subject 
deserving attention. The mind should not be 
goaded or overstrained at this time. See Ado- 
lescence, Anatomic Age. 
PUERPERAL CONVULSIONS.-See Eclampsia. 
PUERPERAL FEVER.-Fever occurring in 
women during the first few days after childbirth. 
It is of two varieties-(1) infectious and (2) non- 
inf ectious. 
Noninfectious puerperal fever may be due to a 
variety of causes. The most common are emo- 
tion, constipation, exposure to cold, and reflex 
irritation. 
PUERPERAL INFECTION.-Infectious puer- 
peral fever may be divided into- 
A. That class in which the infecting agent- 
bacteria or ptomains-gains entrance to some part 
of the genital tract or its vicinity. 
B. That class in which the infection enters the 
body at some point distant from the genital tract, 
as the infectious fevers, erysipelas, and malaria. 
PUERPERAL INFECTION 
Class A. 
Etiology.-The varieties of microorganisms 
capable of producing infection are the streptococci, 
which are the infecting agents in 80 to 95 percent 
of the cases; the staphylococci, the colon bacilli 
(see Colon Bacillus Infection), the gonococci, 
and, in short, any of the germs capable of causing 
local inflammation or general disease. In addition 
to these the saprophytes of decomposition, by the 
manufacture of ptomains, play an important role 
in the commonest form of puerperal sepsis- 
sapremia. These germs gain entrance to the 
genital canal by the hands of the physician, nurse, 
or other attendant; by instruments used in or 
about the parturient tract; by the water used to 
wash and douche the patient; by the bed-clothing, 
personal clothing, vulvar pads, and material used 
to cleanse the vulva; and by the atmosphere, laden 
with dust or vitiated by bad hygienic conditions. 
Putrescible material contained within the genital 
tract, such as decidua, pieces of placenta, and 
blood-clots, forms a suitable area for their multi- 
plication, growth, and dissemination. Finally, a 
certain small proportion of cases may be traced to 
autoinfection-i. e., to the action of germs resident 
in the body and not introduced from without 
during or after labor. Such cases may arise from 
the rupture, during labor, of an old pyosalpinx or a 
suppurating cyst. 
It should be remembered that while a large pro- 
portion of vaginal secretions contain pathogenic 
bacteria, these bacteria are frequently incapable 
of producing disease, since they are in a condition 
of diminished or absent virulence. It should also 
be remembered that the vagina possesses certain 
natural resisting powers against pathogenic in- 
vasion. These powers depend upon a special 
bacillus (Doederlein's) which, by the production of 
lactic acid, is antagonistic to pathogenic bacteria; 
the leukocytosis which is always present, due to PUERPERAL INFECTION 
chemotactic action; the anatomic structure of the 
mucous membrane of the vagina, resembling skin; 
the plug of cervical mucus; and the bloody dis- 
charge during the first few days of the puerperium. 
Classification and Pathology.-The most con- 
venient classification is that one which is depend- 
ent upon the part of the genital tract or its vicinity 
which is most extensively involved. Thus, we 
have the following: 
1. Endocolpitis, endometritis, and salpingitis- 
inflammation of the mucous membrane of the 
vagina, uterus, and tubes. This is most frequently 
of the superficial or suppurative variety; it may, 
however, be ulcerative or phlegmonous. 
2. Metritis and cellulitis-inflammation of the 
uterine walls and pelvic connective tissue. The 
former is the result of septic endometritis, the in- 
flammation having extended beyond the mucous 
membrane and attacked the muscular wall. 
Cellulitis is usually the result of direct extension 
from the uterus; it not infrequently terminates in 
abscess formation. 
3. Peritonitis.-This is the result, usually, of an 
extension through the tubes or a pelvic cellulitis. 
As a rule, the inflammatory process is limited to 
the pelvis; occasionally, diffuse peritonitis is seen. 
4. Uterine and Parauterine Phlebitis.-This is 
caused by infection of blood-clots at the placental 
site. These may be disintegrated and swept into 
the circulation, producing pyemia. Rarely, phle- 
bitis may occur from infection of the wall of the 
vein as it passes through a septic area. 
5. Sapremia.-This is due to absorption of 
ptomains. The ptomains are generated by the 
putrefaction, in the uterus or vagina, of blood-clots, 
decidua, membranes, or placenta. It is the most 
common cause of fever after childbirth. 
6. Septic Cystitis, Ureteritis, and Pyelitis.-This 
is frequently caused by infection from a dirty 
catheter. The condition becomes exceedingly 
grave when the kidney is involved. The in- 
flammation may be suppurative or ulcerative in 
character. 
7. Septic Proctitis.-This is a rare form of infec- 
tion. It may be suppurative or ulcerative. 
Symptoms.-The symptoms may be divided into 
local and general. 
The local symptoms are: (1) Putrid discharge; 
this is not invariably present, but it is seen in the 
majority of instances. (2) Diphtheritic patches; 
these ulcerated areas about the cervix, vagina, and 
vulva are seen in the severer class of cases. (3) 
Edema of the vulva; usually present in more or 
less marked degree. (4) Localized pain and ten- 
derness. (5) Abdominal distention. (6) Inflamed 
tubes and ovaries. (7) Subinvoluted uterus. 
(8) Pelvic exudates and, later, perhaps, signs of 
pelvic abscess. 
The general symptoms are: (1) Rigors or chill, 
followed by rise of temperature. The temperature 
usually ranges between 101° and 104° F.; the chill 
is not infrequently absent. (2) Rapid pulse; this 
is an almost constant symptom. (3) Prostration, 
delirium, and usually constipation. 
All of these symptoms are not to be expected in 
every case of septic infection. Rise of tempera- 
ture and rapid pulse may be the only evidences of 
the condition. 
Differential Diagnosis.-It is desirable to differ- 
entiate the various forms of sepsis. Unfortunate- 
ly, this is not always possible; indeed, two or more 
of them not infrequently occur together. There 
are, however, certain distinctive signs which are 
of value: 
1. Endocolpitis, Endometritis, and Salpingitis. 
-In the former speculum examination will reveal 
a red, swollen mucous membrane, and probably 
patches of ulceration about the vulva, vaginal 
vaults, and cervix. 
2. Metritis and Cellulitis.-The uterus is large, 
boggy, and tender; the discharge is foul and 
copious; exudate may be felt through the vaginal 
vaults; the uterus is firmly adherent. 
3. Peritonitis.-There is a very rapid, running 
pulse; the abdomen is greatly distended and very 
tender; constipation is a marked symptom. 
4. Phlebitis.-The symptoms usually occur late 
in the puerperium; there is high and very irregular 
fever, with marked remissions, sometimes lasting 
4 or 5 days; prostration is profound; phlegmasia 
alba dolens is commonly present; there are no 
severe local symptoms. 
5. Sapremia.-This variety of sepsis should be 
expected if there are moderate fever, rapid pulse, 
and no other well-defined symptoms. A thorough 
disinfection of the birth canal will cause a rapid 
disappearance of these symptoms. 
6. Septic Cystitis, Ureteritis, and Pyelitis.-There 
are pain and tenderness in the lumbar and hypo- 
gastric regions; urination is frequent and painful; 
blood and pus may be found in the urine. 
7. Septic Proctitis.-There are pain in the rec- 
tum, diarrhea, and bloody stools; examination 
will reveal areas of ulceration on the mucous mem- 
brane of the bowel. 
Treatment.-The treatment naturally divides 
itself into the (1) preventive and (2) curative. 
1. Preventive treatment comprises care to avoid 
all sources of puerperal infection. It is con- 
sidered under the management of labor. Careful 
attentions should be paid to the hygiene during 
pregnancy and to the sanitary condition of the 
lying-in chamber. Asepsis of patient, physician 
and accessories is imperative. No more internal 
examinations should be made than are absolutely 
necessary. See Labor. 
2. Curative treatment may be subdivided into 
constitutional, local, and special treatment. 
Constitutional Treatment.-Give (1) calomel 
(1/2 grain) every hour until 4 grains have been 
taken. Follow this with Rochelle salt (1 dram) 
every half-hour until free catharsis is produced. 
(2) Milk (4 to 6 ounces) with lime water (1 fluid- 
ounce) and whisky (1/2 ounce) every 4 hours. 
Broths and beef-tea may be given during intervals 
if the patient can assimilate them. (3) Tincture 
of digitalis (10 drops) and sulphate of strychnin 
(1/20 grain) 4 times daily as long as the pulse is 
above 120 a minute. (4) Suppositories of quinin 
(5 grains) and pyrophosphate of iron (3 grains) 
twice daily. (5) Ergot is indicated to promote 
involution, thereby reducing the absorbent power 
PUERPERAL INFECTION PUERPERAL INFECTION 
of the uterus. (6) Inhalations of oxygen are of 
great value. 
In addition to the foregoing, certain drugs that 
produce hyperleukocytosis, such as nuclein, may 
be tried. Nuclein, in some cases, has appeared to 
give very satisfactory results. Unguentum Crede, 
(a harmless remedy) may be used. Various results 
have been obtained from the intravenous infusion 
of formaldehyd solution. Pryor had excellent re- 
sults with iodoform gauze packing subsequent to 
operation. 
For reduction of the temperature hydrotherapy 
is valuable especially in the form of the wet pack 
or cold sponge. The ice-bag or coil applied in- 
termittently is advocated for local tenderness. 
The subcutaneous injection of a normal salt 
solution, a pint or more 2 or 3 times daily, has 
given good results. It probably acts by causing a 
hyperleukocytosis. Saline enteroclysis may be of 
service. 
Serum Therapy.-Injections of antistreptococcic 
serum have given varied clinical results. If the 
steptococcus be present it may be used, but in 
conjunction with other treatment, as previously 
mentioned. The method of administration is as 
follows: 20 c.c. of reliable serum are injected 
deeply into the tissues as an initial dose. The 
daily dose in a desperate case should be 60 c.c. 
The serum may be tried as a last resort even in the 
absence of a microscopic examination of the 
lochia. 
Local Treatment.-This consists in thorough 
disinfection of the parturient tract as follows: (1) 
Bring the patient in the lithotomy position across 
the bed, with the buttocks projecting well over 
the edge. (2) Sterilize vulva, vagina, instruments, 
and hands. (3) Seize the anterior lip of the cervix 
with a double tenaculum, and draw it well down 
to the vulva. (4) Curette thoroughly, using only 
the force of thumb and forefinger. (5) Remove 
any tabs of decidua or placenta digitally if possible 
-if not, by means of placental forceps. (6) 
Curette again carefully. (7) Irrigate with warm 
sterile water. (8) If the discharge has been very 
offensive, inject into the uterine cavity an emulsion 
of sweet oil (2 ounces) and iodoform (2 drams). 
(9) If the uterus does not contract firmly or if it is 
displaced, insert a light drain of iodoform gauze. 
This constitutional and local treatment should 
be instituted in every case of puerperal sepsis. In 
addition it may be necessary to resort to the 
following: 
Special Treatment. 1. Endocolpitis, Endo- 
metritis, and Salpingitis.-For the first two, re- 
peated douches of sterile water or a 50 percent 
solution of alcohol should be given. If ul- 
cerated areas of mucous membrane are present, 
they should be touched with nitrate of silver 
solution (1 dram to 1 ounce). In suppurative 
salpingitis laparotomy will be required. 
2. Metritis and Cellulitis.-For the former, fre- 
quent intrauterine douches are required; in grave 
cases hysterectomy will be necessary. Cellulitis 
will yield in most cases to free purgation, counter- 
irritation, poultices, and douches; if abscess should 
occur, laparotomy must be performed and the 
PUERPERAL INSANITY 
abscess cavity evacuated and drained. If after 
the abdomen is opened it is found that the inflam- 
mation is confined to the pelvic connective tissue, 
the wound should be closed and the infected area 
opened and drained through the vaginal vault or 
above Poupart's ligament. 
3. Peritonitis.-Salines, stupes, and free stimu- 
lation will be sufficient in mild cases. If active 
symptoms persist far beyond 48 hours, it is prob- 
able that suppuration has occurred. In such a 
case the abdomen should be opened, abscesses 
evacuated and drained, and diseased tubes and 
ovaries removed. It may also be necessary to 
perform hysterectomy. 
4. Phlebitis.-Prolonged rest in bed, free stimu- 
lation, and an abundance of good nutritious food 
is required. If complications occur, such as septic 
pneumonia or arthritis or phlegmasia alba dolens, 
they must be appropriately treated. If one is 
certain that he has to deal with a pure phlebitis, 
local treatment is unnecessary or even harmful. 
5. Sapremia.-Thorough disinfection of the 
parturient tract will cause a disappearance of 
symptoms in from 24 to 48 hours. 
6. Septic Cystitis, Ureteritis, and Pyelitis.-Irri- 
gate the bladder every 4 hours with boric acid 
solution (15 grains to 1 ounce). Use hot stupes, 
salines, and stimulation. Urotropin should be 
given. Abscess of the kidney may necessitate 
evacuation and drainage. 
7. Septic Proctitis.-Irrigate the rectum with 
sterile water, and apply nitrate of silver solution 
(1 dram to 1 ounce) to ulcerated areas. 
Class B. 
The most common varieties of infectious puer- 
peral fever, in which the infecting agent enters the 
body at some point distant from the genital tract, 
are malaria, typhoid, and erysipelas. To elimi- 
nate the first as the cause of fever, give blue mass 
(8 grains) followed by quinin (15 grains); next 
morning give a brisk saline purge and repeat the 
quinin 
PUERPERAL INSANITY.-This is a somewhat 
rare complication of childbirth, occurring once in 
about 400 cases. It commonly manifests itself as 
mania, melancholia, or dementia-the former being 
the most frequent. It usually makes its appear- 
ance during or just after labor, less frequently 
during lactation, and rarely during pregnancy. 
Causes.-The reduction in physical and mental 
power caused by the strain of gestation might be 
considered the predisposing cause. Exciting 
causes are profound emotion, dystocia, anemia, 
albuminuria, and septicemia. 
Diagnosis.-The diagnosis is not difficult, 
although it is important to distinguish it from the 
temporary delirium of labor, the delirium of fever, 
and delirium tremens. 
Prognosis.-With appropriate treatment about 
66 2/3 percent recover their reason in the course of 
a few months. Of the remainder, a small pro- 
portion die from infection or exhaustion, and the 
rest remain permanently insane. 
Treatment.-This consists in the administration 
of tonics and nutritious food; a change of scene, PULMOTOR 
PULSE 
open-air exercise, and general hygienic pre- 
cautions are most beneficial. The patient must 
be constantly watched, lest she attempt some 
injury to herself or child. 
PULMOTOR.-A recent appliance for producing 
artificial respiration in cases of asphyxia. By 
appropriate mechanism, which acts automatically, 
and alternately by pressure and suction, oxygen is 
pumped into the lungs, and then by negative pres- 
sure an outflow from the lungs is caused. The 
apparatus has already achieved great results and is 
most valuable. See New-born Infant (Asphyxia 
Neonatorum). 
PULSE.-Much information of the action of the 
heart, of the blood, and of the artery itself may be 
gained by a simple examination of the radial pulse. 
The physicians in olden times gave much careful 
attention to the pulse, and the amount of infor- 
mation to be gained from its study is astounding. 
By the introduction of percussion, and ausculta- 
tion, the interest in the study of the pulse was de- 
cidedly lessened. This interest was further dim- 
inished by the introduction of the sphygmograph; 
and the clinical thermometer dealt a deathblow to 
the painstaking study of the pulse. 
100 times a minute. He is mainly "interested in 
the dynamics of the viscus rather than in the de- 
rangement of its running-gear." Above all things 
should the family physician be familiar with the 
pulses of his patients in health, for, as is well 
known, some families have abnormally slow and 
others fast pulses. 
The pulse may be modified (1) as to frequency, 
(2) rhythm, (3) volume, (4) tension. 
Frequency.-The normal pulse-rate in the male 
adult may be said to be 76 a minute and 80 for 
the female; at birth it has been placed at 120 to 130, 
and 100 at the second year. 
The frequency of the normal pulse may be 
increased by excitement-such as fright- 
emotion, by violent exercise, and by the use of 
drugs, such as stimulants. An increased fre- 
quency of the pulse is spoken of as tachycardia, 
(q. v.). It is often greatly increased (1) in 
fevers, as scarlet fever, and diphtheria; (2) shock 
from loss of blood; (3) exophthalmic goiter; (4) 
pressure on the base of the brain; (5) organic 
heart-disease, angina pectoris, etc. 
Bradycardia, (q. v.), or a slow pulse, is seen in 
(1) jaundice; (2) atheroma; (3) lesions of the 
cerebral centers; (4) fatty degeneration; (5) 
often after the use of such drugs as aconite, digi- 
talis, and opium; (6) Stokes-Adams syndrome. 
A slow pulse is often a physiologic plenomenon. 
Rhythm.-Often the interval between the beats 
is disturbed, and there will be (1) an intermittent 
pulse or (2) an irregular pulse (arrhythmia). 
Intermittent pulse is often seen in those who 
habitually use tobacco, or after hearty eating. 
It is commonly due to reflex causes, as constipa- 
tion and diseases of the stomach, liver, or kidneys. 
The rheumatic or lithemic diathesis may give rise 
to a slow pulse. 
Irregular pulse is often found in disease of the 
heart-muscle or in disease of its valves. It is 
very common in mitral regurgitation. 
Dicrotic pulse is a condition of the pulse in which 
the first impulse as it strikes the finger is quickly 
followed by another impulse or a secondary wave. 
It is found often in conditions of marked exhaus- 
tion or toxemia as in typhoid fever, and in other 
febrile diseases. 
Quick pulse (puZsus celer) or water-hammer 
pulse (Corrigan's) is a condition of the pulse char- 
acterized by a short, sharp, strong impulse, which 
seems to collapse under the finger. It is best 
detected by holding the arm erect. It is almost 
diagnostic of aortic regurgitation under certain 
conditions. It also occurs in anemia and fevers 
when the arterioles are relaxed. 
Pulsus paradoxus is a pulse in which the wave 
is small and imperceptible during full inspiration. 
It is seen sometimes in health and often in ad- 
herent pericardium. 
Volume.-When the beat of the pulse is large or 
strong, it is known as a full pulse, such as is found 
in plethora or in the robust. If the beat is weak, 
it is known as a small pulse, such as is found in 
debility or exhaustion. 
Strength.-A strong pulse is one in which there 
are little compressibility and a strong impulse, such 
A. Steel spring. B. First lever. C. Writing lever. C' 
Its free writing end. D. Screw for bringing B in contact 
with C. G. Slide with smoked paper. H. Clockwork. L. 
Screw for increasing the pressure. M. Dial, indicating the 
pressure. K, K. Straps for fixing the instrument to the 
arm and the arm to the double inclined plane or support. 
Marey's Sphygmograph.-(Greene.) 
To take the pulse, the physician should be seated 
by the side of the patient, who should be in a 
sitting or recumbent posture, with arm extended 
and resting on some support. The physician 
should lightly place the 4 fingers of his right hand 
over the left radial artery of the patient, with his 
index-finger nearest patient's hand; the little 
finger will thus be the first to receive the stroke. 
The pulse should always be taken at each wrist, 
for reasons to be given later. By so doing the 
presence of aneurysms may often be suspected and 
frequently verified. Pressure should be made and 
relaxed alternately. Points to be noticed are: 
(1) The size of the artery; (2) pulse rate or fre- 
quency; (3) regularity of rhythm; (4) uniformity of 
strength; (5) synchronism and equality of the right 
and left radial pulses; (6) the force required to oblit- 
erate them (tension); (7) abnormal thickening of 
the artery (arteriosclerosis). A strong pulse is 
characterized by volume and vigor; a weak one by 
the reverse conditions. The number of pulsations 
to the minute, which can generally be counted 
accurately by means of a watch, is the least impor- 
tant of all the points to the experienced clinician, 
who cares little whether the heart contracts 75 or PULVIS 
PURPURA 
as is found in hypertrophy of the heart. Its op- 
posite is a weak pulse, as in adynamic states. 
Tension or Resistance.-It may be either hard 
or soft. A hard pulse is one of high tension, or 
one in which there is great contractile power; it is 
often seen in hypertrophy of the left ventricle, 
interstitial nephritis, septicemia, angina pectoris, 
arteriosclerosis; certain intoxications like gout, 
lead poisoning, diabetes in elderly persons. It 
is observed in apoplexy and at times in anemia. 
A small, hard, wiry pulse is noted in the early 
stage of peritonitis. A soft pulse is of low tension 
and easily compressible, indicative of a loss of 
tone in the arterial coats. It is found in low 
.fevers, such as typhoid, the later stages of pneu- 
monia, and in adynamic conditions in general. 
It is sometimes hereditary and may be observed 
in obesity. See Heart-disease (Functional). 
PULVIS.-See Powder. 
PUMPKIN SEED.-See Pepo. 
PUPIL, CHANGES IN MOTILITY.-Mydriasis, or 
extreme dilatation of the pupil, occurs under the 
effects of drugs possessing a mydriatic action, 
such as atropin, homatropin, hyoscyamin, etc.; 
in glaucoma; in optic nerve atrophy; in diseases 
of the orbit; after fright; in neurasthenia; after 
irritation of the cervical sympathetic, as by an 
aneurysmal tumor; and sometimes in idiots. 
Permanent mydriasis has occurred after the 
instillations of a mydriatic have been suspended. 
Mydriasis of distinctly cerebral origin is caused 
either by irritation due to some lesion in the 
brain or cervical portion of the spinal cord, or by 
paralysis of the oculomotor center due to hemor- 
rhage, thrombosis, tumor, or abscess of the brain. 
The treatment of mydriasis consists in remedy- 
ing the cause, if possible; locally, pilocarpin or 
eserin is indicated, and the galvanic current is 
sometimes of use. Exercise of the eyes with con- 
vex lenses upon near objects may be of value. 
Miosis, or permanent contraction of the pupil, 
occurs under drugs possessing miotic action, such 
as eserin, pilocarpin, etc.; in paralysis of the 
cervical portion of the spinal cord, particularly in 
locomotor ataxia; in paretic dementia; in cere- 
bral syphilis; and in bulbar palsy, with progres- 
sive muscular atrophy. Persons who continu- 
ally use their eyes on fine objects, such as watch- 
makers and engravers, sometimes suffer from 
miosis. In opium-poisoning the pupil is reduced 
to the size of a pinpoint, dilating just before 
death. Nicotin and alcohol in poisonous quan- 
tities may produce miosis. As contraction of the 
pupil may result from irritating cerebral lesions 
similar to those causing dilatation, it is important 
to have some means of differential diagnosis. 
Berthold mentions that miosis occurs in a sudden 
attack of paralysis due to embolism, and my- 
driasis in an attack due to ophthalmia. Idiopathic 
cases are said to result from syphilis, tuberculosis, 
rheumatism, and other systemic disorders. 
Treatment is virtually the same as that for 
iritis, although atropin must be used with caution, 
as it is often very poorly borne. Plastic and 
purulent cyclitis must be treated rigorously with 
mercurial inunctions. For the reduction of 
tension, the local use of eserin, diaphoretics, and 
paracentesis are indicated. In purulent cyclitis, 
especially after operations, antiseptic douches 
are indicated. On account of the uncertain 
prognosis, the possibility of relapses, disorganiza- 
tion of the vitreous, and sympathetic ophthalmia, 
the patient must be carefully watched, and ex- 
pectant treatment continued after the symptoms 
have subsided. 
Anisocoria, or inequality in size of the pupils, 
may occur in perfect health. In fact, it is much 
more common than text-books indicate. It is 
sometimes seen in eyes of widely dissimilar re- 
fraction, diseases of the brain and nervous sys- 
tems, and in insanity. It is not uncommon in 
tabes, disseminated sclerosis, and paretic de- 
mentia. 
Wernicke's sign, or hemiopic pupillary inac- 
tion, is mentioned in the discussion of Hemianopsia 
(g. v.). Light is carefully thrown on the blind 
side of the retina; if there is reflex contraction, 
the lesion is behind the pupillary centers; if there 
is no reflex obtained, the lesion is at or in front of 
the pupillary centers. 
The Argyll Robertson pupil is a name given to 
a reflex pupillary rigidity producing loss of reac- 
tion to light stimulation, although the action 
to accommodation and convergence may still be 
present. It is a diagnostic sign of value in loco- 
motor ataxia, but has been noticed in general 
paralysis of the insane, in cerebral syphilis, 
and is the result of poisoning by bisulphid of 
carbon. 
The orbicularis pupillary reaction refers to con- 
traction of the pupil when a forcible effort is made 
to close the lids. 
Hippus is the name given to the oscillatinos 
occurring after contraction to light. It is ex- 
aggerated in hysteria, disseminated sclerosis, 
epilepsy, and in the early stages of acute 
meningitis. 
Iridodonesis is a tremulous condition of the iris, 
due to lack of a normal support of the lens. It is 
seen in conditions in which the lens is dislocated 
posteriorly, in atrophy of the vitreous, in over- 
ripe cataract, and after cataract extraction. 
PURGATIVES.-See Cathartics. 
PURPURA (Peliosis Rheumatica).-A hemor- 
rhagic disease characterized by the appearance 
on the skin of variously sized and shaped red- 
dish-purple macules, not disappearing under 
pressure. 
Varieties.-There are 3 chief varieties, distin- 
guished by the premonitory and concomitant con- 
stitutional symptoms, by the extent of hemor- 
rhagic extravasation, and by the cause: (1) 
Purpura simplex; (2) purpura rheumatica; (3) pur- 
pura haemorrhagica. 
Purpura Simplex. 
The eruption, usually appears suddenly and con- 
sists of pinhead-sized to bean-sized, round, oval, 
irregular, claret-red or purplish spots. They are 
circumscribed, smooth, and nonelevated, and are 
symmetrically distributed, tending particularly to PURPURA 
PYELITIS 
occur upon the lower extremities. Subjective 
symptoms are, as a rule, absent. There is com- 
monly no systemic disturbance, and the disease 
tends to a favorable termination in the course of a 
few weeks. 
Purpura Rheumatica (Peliosis Rheumatica). 
This form is ushered in with fever, lassitude, 
anorexia, and severe rheumatoid pains, particularly 
in the lower extremities, the joints of which may 
be swollen. The eruption consists of well-defined, 
splitpea-sized to finger-nail-sized hemorrhagic 
patches which may be slightly elevated or level 
with the skin. At first of a pinkish, reddish, or 
purplish color, they later pass through the color 
transitions of all ecchymoses. The eruption is 
more or less generalized, but is most marked upon 
the extremities. The disease may last a few weeks 
or persist, in the form of relapses, for several 
months. It is sometimes associated with ery- 
thema multiforme. 
3. Onset slow. 
4. Gums spongy, swol- 
len, and bleeding; 
teeth loose. 
5. Severe muscular 
pains. 
6. Brawny infiltration 
of lower extremities. 
7. Hemorrhages from 
mucous membranes 
not, as a rule, pro- 
fuse. 
3 Onset sudden. 
4. Gums often bleeding 
but not swollen. 
5. Less marked. 
6. Not present. 
7. Hemorrhages from 
mucous membranes 
often so severe as to 
prove fatal. 
Prognosis.-In purpura simplex and rheumatica 
the prognosis is favorable, recovery taking place ir^ 
several weeks or months. In purpura haemor- 
rhagica the prognosis is more guarded, a certain 
number of cases succumbing to internal hemor- 
rhage. 
Treatment.-The treatment of purpura must be 
adapted to the exigencies of the individual case. 
Ergot, tincture of the chlorid of iron, quinin, tur- 
pentine, and the mineral acids are useful in all 
forms of the disease. In purpura rheumatica and 
haemorrhagica the patient should be confined to his 
bed and placed upon a nutritious and easily 
assimilable diet. Locally, astringent lotions and 
ice, if necessary, may be employed. 
PUS.-See Suppuration. 
PUSTULANT.-See Counterirritation. 
PYELITIS (Pyelonephritis).-Inflammation of 
the mucous membrane of the pelvis of the kidney. 
Except in the mildest cases, the kidney proper 
becomes simultaneously involved. To the former 
condition the term pyelitis is applied; to the latter, 
pyelonephritis. 
Etiology.-(1) Renal calculus; (2) secondary to 
urethritis or cystitis; (3) tuberculosis; (4) after 
infectious diseases, such as typhoid fever, scarlet 
fever, diphtheria, small-pox; (5) carcinoma. 
Microorganisms may gain access to the kidney 
either through the blood stream or through the 
urinary tract. When infection occurs in the 
former way it is called hematogenous; when in the 
latter, urogenous. See Colon Bacillus Infec- 
tion. 
Pathology.-The mucous membrane of the pelvis 
of the kidney is swollen, turbid, and often shows 
minute extravasations. The epithelium has in 
certain areas undergone degeneration, forming 
mucus or pus. The suppurative process may 
finally extend into the kidney structure, giving 
rise to pyelonephritis, and a large abscess may 
occupy the entire area of the kidney. In certain 
instances the fluid material may be entirely 
absorbed, leaving a putty-like material. 
Symptoms and Clinical Course.-There is pain in 
the lumbar region and also anteriorly, detected on 
deep pressure. The fever is irregular, occasionally 
accompanied by hectic symptoms, with sweat and 
chill. In some cases the disease may simulate 
typhoid fever. The urine is clear at times, but 
generally has a turbid color, with a heavy precipi- 
tate containing a large amount of mucus, pus-cells, 
red blood-corpuscles, and pelvic epithelium. 
Blood-clots may be passed. 
Purpura Haemorrhagica (Morbus Maculosus 
Werlhofii; Land Scurvy). 
The onset of the hemorrhagic form is signalized 
by the occurrence of fever and symptoms of 
systemic depression. The eruption consists of 
hemorrhagic patches varying in size from that of 
a small coin to that of the palm of the hand,- 
which come out suddenly and in considerable 
numbers. The trunk and extremities are the 
regions usually involved. At the same time, 
bleeding from the mouth, gums, nostrils, bowels, 
bladder, etc., may take place. The disease may 
terminate in a fortnight or may continue for 
weeks. In a certain number of cases it proves 
fatal. 
Etiology.-The causes of purpura are obscure. 
The disease, especially the hemorrhagic type, 
occurs more often in debilitated individuals. 
Some look upon the vasomotor apparatus as the 
agency primarily at fault; others believe purpura 
to be an infectious disease. Such drugs as arsenic, 
potassium iodid, chloral, quinin, and the sali- 
cylates may produce hemorrhagic eruptions. 
Pathology.-As a result of an alteration in the 
blood or blood-vessel walls an extravasation of 
blood takes place into the tissues. After a 
variable period of time this undergoes resorption, 
the changes in the blood pigment producing the 
varying colorations. The process is not attended 
with inflammation. 
Diagnosis.-The evident hemorrhagic nature of 
the lesions and their failure to disappear upon 
pressure distinguish them as purpuric. Purpura 
haemorrhagica may be confounded with scorbutus: 
Scorbutus. 
1. Occurs in those sub- 
ject to lack of vege- 
table food and to 
bad hygiene. 
2. Definite premonitory 
symptoms: weak- 
ness, impaired cir- 
culation, etc. 
Purpura PLemorrhagica. 
1. No such etiologic re- 
lationship. 
2. Premonitory signs 
slight or absent. PYEMIA 
PYORRHCEA ALVEOLARIS 
The purulent material renders the urine 
albuminous. 
Diagnosis.- 
Pyelitis. 
Nephritis. Cystitis. 
1. History of case.. 
2. No tube casts.. 
3. Pus in urine.... 
4. Dropsy rare .... 
1. Increased mictu- 
rition ; sweat and 
chills rare. 
2. Albumin and vari- 
ous kinds of casts. 
3. Pus rare 
1. Micturition ac- 
companied by 
tenesmus; often 
burning pain. 
2. No tube casts. 
3. Blood often at 
end of micturition. 
4. No dropsy. 
4. Dropsy common. 
5. Urea diminished 
or into the surrounding tissue, causing a peri- 
nephritic abscess. 
Etiology.-Infective nephritis with retention of 
pus is a very common cause, but some cases of pyo- 
nephrosis are due to infection of a hydronephrosis. 
Symptoms.-In addition to a tumor in the abdo- 
men with characters similar to those of hydro- 
nephrosis, there will be pain in the tumor, espe- 
cially on pressure, and if the obstruction of the 
ureter is incomplete, pus in the urine, septic fever 
varying with the absorption. 
Treatment.-Nephrotomy, with removal of any 
obstruction discovered in the pelvis of the kidney 
or ureter. If after nephrotomy, however, the 
cyst does not shrink and cease to suppurate, and 
the opposite kidney is sound and working well 
enough, nephrectomy may have to be done, as 
otherwise lardaceous disease may carry off the 
patient, or blood-poisoning may ensue from the 
discharge becoming septic, or, as sometimes 
happens when the obstruction of the ureter is 
relieved to some extent by the nephrotomy, the 
decomposing pus may make its way into the blad- 
der, set up cystitis, and the other kidney become 
affected. When the disease is bilateral both kid- 
neys are drained through the loins. See Pyelitis. 
PYORRHCEA ALVEOLARIS.-Riggs' Disease, 
Phagedenic Pericementitis (Black), Interstitial 
Gingivitis (Talbot), Phagedenic Pericemental 
Alveolitis (Logan). 
Definition.-A chronic destructive disease of the 
supporting structures of the human tooth. 
Etiology.-The usual systemic predisposing causes 
are diseases of the heart and vessels, diabetes and 
Bright's disease. Chronic rheumatism and diges- 
tive disturbances are held to be the most serious 
predisposing factors. Local predisposing causes: 
Lack of maintenance of proper hygiene; absence 
of normal contacts and masticatory influences; 
excessive irregularities and malocclusion of the 
teeth. Local exciting causes: Presence upon the 
crown and root surfaces of teeth of inorganic and 
organic deposits of a fatty glue-like substance im- 
pregnated with pyogenic bacteria; lodgment of 
food in the interproximal spaces; the presence of 
pyogenic organisms that chronically involve the 
pericemental alveolar structures which normally 
support the teeth. The entamoeba buccalis has been 
found in many cases. 
Diagnosis.-This disease exists whenever se- 
rumal deposits are found upon the exposed ce- 
mentum, and a septic chronic destructive inflam- 
mation coexists in the pericemental and alveolar 
structures, providing this exposed cementum re- 
sulted from some disturbance that had its origin 
of irritation in the gums. This disease exists also 
when we find a chronic septic destructive process 
beginning at the gums and progressively involving 
the pericemental and alveolar tissues in such a 
manner as to create well defined pockets in the 
form of narrow routes at the expense of the peri- 
cemental tissues and the inner surface of the 
alveolar structures some distance in advance of the 
alveolar rim involvement. According to the above 
diagnostic findings phagedenic pericemental al- 
veolitis exists without serumal deposits being 
Prognosis.-The prognosis is variable; simple 
pyelitis may exist for years without the substance 
of the kidney itself becoming involved. Pyelo- 
nephritis, as a rule, gradually leads to destruction 
of the kidney and therefore must be considered a 
serious disease. 
Treatment.-The treatment of acute pyelitis 
consists in the employment of antiphlogistic 
measures and the administration of narcotics and 
urinary antiseptics. Of the latter urotropin is the 
most valuable. Regular evacuation of the bowels 
should be secured. If threatening symptoms 
persist, such as high fever and chills, and if an 
exact diagnosis can be made as to which kidney is 
diseased, or at least as to which one is the more 
diseased a brilliant curative effect can sometimes 
be secured by splitting the kidney. This applies 
to pyelitis as well as pyelonephritis, but is only of 
value in the ascending forms of the disease. 
In chronic pyelitis, and pyelonephritis, the 
use of urinary antiseptics and the employment of 
hygienic measures are also indicated. For pyelitis 
due to infection with the gonococcus or colon 
bacillus Casper recommends irrigation of the renal 
pelvis with a solution of silver nitrate 1 : 1000. 
In chronic pyelonephritis nephrotomy often brings 
about a cure. See Kidney (Injuries, Surgery), 
Nephritis. 
PYEMIA.-Phlebitic septicemia, with the pres- 
ence of pyogenic microorganisms in the blood and 
with the formation, wherever they lodge, of 
secondary embolic or metastatic abscesses. It is 
characterized by intermittent fever, with recurrent 
rigors, profuse sweats, a sweetish odor to the 
breath, a dry, brown tongue, and rapid emaciation. 
Slight jaundice frequently develops; sometimes, 
also, a purpuric eruption; the temperature may 
be very high-105° F., or even more. It usually 
terminates in death. See Sepsis. 
PYLORUS.-See Stomach. 
PYOKTANIN.-See Methyl-violet. 
PYOMETRA.-See Hematometra. 
PYONEPHROSIS.-Pyonephrosis is the dis- 
tention of the pelvis and calices of the kidney with 
pus, and the subsequent destruction, more or less 
complete, of the medullary and cortical substance, 
the whole kidney being at length converted into a 
large multilocular suppurating cyst. This cyst 
may rupture into the peritoneal cavity or colon, PYORRHOEA ALVEOLARIS 
PYROPLASMOSIS HOMINIS 
found in the pockets as well as with them. How- 
ever, in over 90 percent of the advanced cases 
serumal deposits are present. 
Subjective Symptoms.-Patients as a rule not 
aware of the presence of the disease until it has 
progressed to a serious stage; then low, dull, gnaw- 
ing pains are experienced in the part for a few 
days at a time, with variable periods of rest from 
discomfort. In advanced cases tenderness is 
felt when masticating food. 
Objective Symptoms.-Deep dark red discolora- 
tion of the gums and adjacent soft tissues over- 
lying the bone structures about the roots involved. 
Excessive hemorrhage from gums from the slight 
irritations caused by thorough examination, the 
usual brushing, and the mastication of food. Suffi- 
ciently pronounced hemorrhage occurs sometimes 
during sleep to saturate the pillow. In advanced 
cases pus can be forced up around the necks of the 
teeth involved from practically all of the pockets 
found. The teeth eventually become abnormally 
mobile and permanently shift from their normal 
positions causing characteristic deformities. The 
roots gradually become exposed as the supporting 
structures are progressively destroyed. 
Treatment, 'operative, consists in the removal 
of all deposits found upon the exposed cementum in 
the pockets. Smooth the roughened cementum 
with sharp instruments and polish with pumice 
and orangewood point all exposed tooth surfaces. 
Surgical, remove all degenerating pericemental 
fibers from the tissues forming the borders of the 
pockets, carefully examining remaining alveolar 
process and if carious areas are found, these areas 
are to be curetted. Medicinal, irrigate pockets 
during operative and surgical treatment with 
a physiological salt solution, which is to be made 
fresh for every patient. Senn's solution should 
be employed for the final medicinal treatment in 
the pocket. Tincture of iodin for local applica- 
tion to be applied upon the gums and overlying 
structures is sometimes beneficial in causing the 
acute inflammation to subside. The constant 
use of astringent mouth washes acts against rather 
than in favor of gaining and maintaining control 
of this disease. Tooth powders and mouth washes 
should never be relied upon to cure this condition; 
still proper oral and dental cleanliness is necessary 
for the prevention of the beginnings of excessive 
dental caries and diseased conditions of the gums. 
The use of emetin has been recommended but it is 
impossible to say, as yet, whether it will always 
give the good results which have been claimed for it. 
Dilute sulphuric acid (in 20 to 30 minim doses, has 
also been advocated. 
Prosthetic Treatment.-A reestablishment of all 
lost contacts and the fixation of the abnormally 
loose teeth is to be brought about by the con- 
structing of metal splints that are to be cemented 
into place. 
Prognosis for single rooted teeth when only the 
gingival third is involved, is good; when the middle 
third is extensively involved prognosis is only 
fair; when the apical third is extensively involved 
the tooth should be immediately extracted. 
Prognosis of multiple rooted teeth when gingival 
third is involved is good; but when middle third is 
extensively involved the tooth should be ex- 
tracted or one of the roots excised. 
PYOSALPINX.-See Fallopian Tubes. 
PYOTHORAX.-See Pleurisy (Purulent). 
PYRAMIDON.-A derivative of antipyrin in 
which an H-atom of the pyrazolon group is re- 
placed by a dimethylamido group. It forms a 
yellowish-white, tasteless, crystalline powder, solu- 
ble in water (1 :10). This solution gives a violet 
fugitive color with Fe2Cl8. Nitrous acid gives an 
evanescent violet. In the urine pyramidon is 
best detected by the ferric chlorid test. The 
action of pyramidon upon the nervous system is 
analogous to that of antipyrin, but it is active in 
much smaller doses. It is much milder, more 
gradual and lasting in its influence than antipyrin. 
Dose, 2 to 8 grains. For consumptives and in 
hectic fever the minimum dose should not be ex- 
ceeded. P. Acid Camphorate and P. Neutral 
Camphorate. The acid and neutral salts combine 
the antipyretic action of pyramidon with the 
antihidrotic action of camphoric acid, the former 
action predominating in the neutral salt, the 
latter in the acid salt. It is said that the tonicity 
of pyramidon is thereby reduced, while the cam- 
phoric acid has greater antihidrotic power. They 
are especially efficacious in the night-sweats of 
phthisis. Dose of the neutral salt, 8 to 12 grains; 
of the acid salt, 12 to 15 grains. 
P. Salicylate is antipyretic, analgesic and anti- 
septic, combining the activity of its components, 
pyramidon and salicylic acid. It is recommended 
in rheumatic and gouty affections, neuralgia, 
pleuritis, etc. Dose, 8 to 12 grains. 
PYRETHRUM (Pellitory).-The root of Ana- 
cyclus pyrethrum. It contains an alkaloid pyre- 
thrin, also inulin, tannin, mucilage, etc., with a 
brown resin and two fixed oils. When taken into 
the mouth, it increases the flow of saliva, and 
is used as a masticatory in dry conditions of the 
mouth, in relaxed states of the throat, and in 
aphonia; also in headache and facial neuralgia. It 
is valuable mainly as a masticatory and sialagog. 
Dose, 10 to 45 grains. P., Tinct., 20 percent; used 
externally. P. roseum, Persian pellitory. The 
powdered flower-heads are used as an in- 
secticide. 
PYROGALLOL. C8H3(OH)A triatomic phe- 
nol obtained chiefly by dry distillation of gallic 
acid, occurring in light, white, shining laminae or 
fine needles; of bitter taste, but soluble in water, 
alcohol, and ether. Dose, 1 to 2 grains. It is a 
powerful reducing agent, and is used as a disin- 
fectant in 1 to 2.5 percent solutions. As an oint- 
ment (1 dram to 1 ounce) it ranks next to chrysa- 
robin, for use in psoriasis, while in lupus and epi- 
thelioma it is supposed to attack only the dis- 
eased nodules, leaving uninjured the adjacent 
skin. By the mouth, for internal hemorrhage, it 
has been used in 20-grain doses. Large doses may 
produce hemoglobinuria and general disorganiza- 
tion of the blood-corpuscles. 
PYROPLASMOSIS HOMINIS.-A peculiar fatal 
disease of certain parts of Idaho, Wyoming, Mon- 
tana, Nevada, occurring during the spring and PYROPLASMOSIS HOMINIS 
PYURIA 
early summer, apparently only in persons who 
have been bitten by ticks. Certain observers 
believe it to be due to the pyroplasma hominis, 
which is closely related to the pyrosoma bigem- 
inum, the cause of Texas cattle fever, and is 
believed to be transmitted by means of the bite 
of a tick (though the latter may be overlooked 
by reason of its presence at times only in the 
hair above the genitals). This organism is 
found in the patient's blood. 
Symptoms.-After an incubation period of 
from 3 to 10 days, headache, nausea, muscular 
soreness, and a chill or chilliness and nose-bleed 
are followed by a rapidly rising fever and unduly 
rapid pulse and respiration. On the third day 
a rash, macular, bright red, in severe cases pete- 
chial, appears first on the forehead and extremities, 
later on the chest, abdomen, and back. It is 
profuse except on the abdomen. Desquamation 
may'follow. Albumin is present in the urine. In 
fatal cases rapid anemia appears with sustained 
high temperature and rapid weak pulse. About 
the twelfth day the temperature falls by lysis in 
favorable cases, but 70 to 90Lpercent terminate 
fatally. 
Prophylaxis.-It is wise not to live in these dis- 
tricts during the spring and early summer. Tick 
bites should be guarded against, but if incurred, 
ammonia, kerosene or turpentine should be ap- 
plied, followed by cauterization with pure phenol. 
Treatment is stimulating and symptomatic. 
PYROSIS (Heartburn).-An affection of the 
stomach characterized by a burning sensation, 
accompanied by eructations of an acrid, irritating 
fluid. See Gastric Neuroses, Gastritis. 
PYROXYLIN (Soluble Gun-cotton).-Chiefly 
tetranitrate of cellulose, used for preparing collo- 
dions. Collodion rapidly dries on exposure to 
air by evaporation of its ether and leaves a trans- 
parent film of pyroxylin on the surface to which 
it has been applied. This film, if the flexible col- 
lodion be used, will not contract or crack on drying. 
PYURIA. - See Cystitis, Pyelitis, Urine 
(Examination). QUARANTINE 
QUININ 
Q 
QUARANTINE.-The time (formerly 40 days) 
during which a vessel from ports infected with con- 
tagious or epidemic diseases is required by law to 
remain outside the port of its destination, as a 
safeguard against the spreading of such disease. 
The necessity and means of quarantine in infectious 
diseases are discussed under the separate headings 
of the different diseases. The methods of disin- 
fection are considered under the heading Disin- 
fection (q. v.). 
QUASSIA.-The wood of Picrasma excelsa, or 
of Quassia amara; the former is known commer- 
cially as Jamaica quassia, and the latter as Surinam 
quassia. The wood is turned into cups, which are 
sold under the name of quassia- or bitter-cups. It 
contains a bitter principle, Quassin, C31H42O9, 
which is crystalline, soluble in hot alcohol and in 
chloroform, slowly in cold water, faster in alkaline 
or acidulated water. Dose of the powdered wood, 
5 to 15 grains. Quassia is fatal to flies and fish, 
and makes an excellent anthelmintic enema 
against the thread worm. The lower bowel should 
be washed out with soap and water, and from 1/2 
to 1 pint of an infusion, made by adding 1 or 2 
ounces of quassia chips to a pint of water, should 
be injected and retained for some minutes. 
Several such injections will invariably kill seat- 
worms or thread-worms, but enough fluid should 
be injected to reach high up in the rectum, and 
the washing with soap and water should not be 
omitted. Quassia contains no tannin, and may 
be prescribed with salts of iron. In atonic 
dyspepsia, with pain after eating and regurgitation 
of food, and to promote appetite and digestion, it 
is much employed. 
A bitter tonic: 
I|. Extract of nux vomica, gr. iv 
Extract of quassia, gr. xx 
Sulphate of quinin, gr. xl. 
Make into 20 pills. One pill 3 times daily 
after meals. 
Preparations.-Q.-cup, a cup made of quassia 
wood, called also bitter-cup, from which water may 
be drunk, the bitter principles becoming dissolved 
in the water. Q., Ext., its properties are due to a 
bitter principle, quassin. Dose, 1 to 3 grains. 
Q. Fluidextract. Dose, 5 to .15 minims. Q., 
Infus., quassia chips, 1 dram; water, 10 ounces. 
Dose, 1 to 3 ounces. Q., Tinct., 20 percent in 
strength. Dose, 5 minims to 1 dram. 
QUEEN'S-ROOT.-See Stillingia. 
QUERCUS (White Oak).-The bark of the white 
oak tree. It is astringent and tonic, but seldom 
used internally, its action being that of tannic 
acid. A decoction or infusion is much used as a 
cheap astringent application in leukorrhea, vagi- 
nitis, gonorrhea, prolapsus ani, hemorrhoids, etc., 
and as a gargle in faucial inflammations and for 
prolapsed uvula. It stains the clothing very 
slightly. Q. tinctoria stains the clothing very 
badly, but it is equally efficient. As an astringent 
poultice, the powdered bark is used to check 
discharges of freely running sores. An infusion 
of 1 ounce to a pint of water is of sufficient 
strength. Q. Fluidextract. Dose, 5 to 20 minims. 
QUICKENING.-The first sensation of the 
movements of the fetus in a pregnant woman. It 
usually occurs at about the twentieth week. 
Some women experience it earlier than this, and 
in some it appears to be entirely absent. It has 
been likened in character to the fluttering of a bird 
held in the partly closed hand. It is one of the 
important subjective signs of pregnancy. See 
Pregnancy (Diagnosis). 
QUICKSILVER.-See Mercury. 
QUILLAJA (Soap Bark).-The inner bark of 
Quillaia saponaria. Its properties are due to a 
glucosid, saponin. It is a sternutatory, irritant to 
the mucous membranes, and an expectorant hav- 
ing an agreeable taste. Dose of a 5 : 200 decoction, 
1 to 2 drams, according to age. 
QUINIDIN.-A cinchona alkaloid, isomeric with 
quinin, with which it corresponds in therapeutic 
effects; but it is thought to produce less unpleas- 
ant symptoms in the head. Q. Sulph., readily 
soluble in acidulated water and alcohol; it is an 
excellent antipyretic and antiperiodic. Dose, 20 
to 60 grains or more. Q. Tannate, used in diar- 
rhea, nephritis, and malaria. Dose, 2 to 12 grains 
twice daily. 
QUININ.-Quinin is a finely crystalline or 
amorphous white alkaloid obtained from various 
species of Cinchona (5. v.). It is odorless, very 
bitter, alkaline in reaction, and soluble in 
1600 parts of cold water or 0.6 parts of 
alcohol. It is a valuable tonic, antiseptic, antipy- 
retic, and antiperiodic. Quinin and its salts are 
distinguished from all other alkaloids, excepting 
quinidin and quinicin, by the emerald-green color 
given to their solution by chlorin water followed 
by ammonia. 
Therapeutics.-Quinin finds its principal field of 
action in the malarial diseases, over which its 
influence is specific, by reason of its power to 
prevent the development of the plasmodium to 
which malaria is due. In intermittent fevers a 
10-grain dose of the sulphate should be given in the 
sweating stage, and again 5 hours before the ex- 
pected time of the next paroxysm. In the in- 
tervals arsenic is better used, as quinin may cause 
a daily exacerbation of temperature if long con- 
tinued. In remittent fevers 20- to 30-grain doses 
should be administered once or twice a day until 
the temperature is reduced to the normal point. 
In pernicious remittent fevers large doses (30 to 40 
grains) are necessary to the safety of the patient. QUININ 
QUINSY 
In chronic malarial poisoning quinin has consider- 
able power, but chinoidin is more effective. 
Quinin (5 to 10 grains daily) is efficient as a pro- 
phylactic against malaria. See Malarial Fevers. 
As an antipyretic, quinin is used with the best 
results, especially in septic fevers, typhus, typhoid, 
variola, pneumonia, and acute rheumatism. In- 
flammations may, at their inception, be aborted 
by 15- or 20-grain doses, combined with morphin, 
which in this respect is synergistic to quinin. 
Acute tonsillitis and acute catarrh may sometimes 
be aborted by a full dose. In surgical fevers, 
pyemia, and exhausting suppurative conditions, 
also in septicemia, hectic fever, and before surgical 
operations, quinin is much employed. Neuralgias 
of malarial origin are amenable to it, as also neural- 
gia of the ophthalmic division of the fifth nerve. 
In eruptive fevers-especially scarlet fever, 
erysipelas, and measles-it is advantageously ad- 
ministered throughout their course. In some 
skin-diseases-particularly erythema nodosum-it 
is quite efficient, also in whooping-cough and hay- 
fever. In the latter affection a solution of 6 grains 
to the ounce of the neutral hydrochlorid is a very 
useful local application. Of internal antipyretics, 
the safest and best is quinin, next in order being 
phenacetin. Quinin hydrobromid has recently 
been recommended for use in exophthalmic goiter. 
Warburg's tincture has obtained a very high 
reputation in the hands of Indian army-surgeons 
in the treatment of remittent and other malarial 
fevers of the most malignant types, in malarial 
neuralgias, acute nervous exhaustion, and sudden 
collapse without organic disease. 
Poisoning.-The heart and the arterial tension 
are somewhat stimulated by small doses, but de- 
pressed by large ones (40 to 80 grains), which 
slow and enfeeble the pulse by direct action on the 
cardiac ganglia. The brain is rendered hyper- 
emic and exhilarated by small or moderate 
doses, but large ones produce a sense of fulness 
and constriction in the head, cerebral anemia, 
pallor, tinnitus aurium, vertigo, staggering gait, 
amaurosis and deafness, great headache, dilated 
pupils, delirium, coma, and, in animals, convul- 
sions. The eyes and ears are very rarely injured 
permanently. These symptoms collectively are 
termed Cinchonism (q. v.). 
Preparations.-Quinina, a white, amorphous 
or minutely crystalline powder, of alkaline re- 
action and very bitter taste, soluble in 1670 of 
water and in 0.6 of alcohol at 59° F. and readily 
in dilute acids. Dose, 1 to 20 grains, or 40 grains 
in special cases. Is insoluble in saliva. Q. Bi- 
sulphas, clear, colorless efflorescent crystals or 
small needles, of . very bitter taste and strongly 
acid reaction, soluble in 10 of water with blue 
efflorescence, and in 32 of alcohol at 59° F. Dose, 
1 to 20 grains, or even 60 grains in special cases. 
Q. Hydrobromidum, colorless needles, of very 
bitter taste, soluble in 54 of water and in 0.6 of 
alcohol at 59° F., very soluble in boiling water and 
in boiling alcohol. Dose, 1 to 20 grains. Q. 
Hydrochloridum, white needles in tufts, of very 
bitter taste, soluble in 34 of water and in 3 of 
alcohol at 59° F., in 1 of boiling water or alcohol. 
Dose, 1 to 20 grains. An excellent salt which 
should be more generally used; 5 to 10 grain 
doses are antipyretic. Q. Hydrochloridum Acidum 
(B.P.) is soluble in less than its own weight of 
water, and may be used hypodermically. Dose, 
1 to 10 grains. Q. Salicylas is soluble in 77 of 
water, in 11 of alcohol, in 37 of chloroform, and 
in 110 of ether, at 77° F. It contains 70 percent 
of quinin. Dose, 1 to 20 grains in pill or capsule, 
Q. Sulphas, very light, snow-white, fragile crystals, 
of bitter, persistent taste, soluble in 740 of water 
and in 65 of alcohol at 59° F., more soluble in 
acidulated water. Dose, 1 to 20 grains, or even 
40 grains in special cases. Tinctura Pyrexialis, 
Tinctura Antiperiodica, or Warburg's Tincture 
(Unofficial) is a celebrated and formerly secret 
preparation. The formula, published by the origi- 
nator, included over 60 ingredients, one of which 
(Confectio Damocratis) contained many drugs 
which are not now obtainable. The tincture con- 
tained quinin bisulphate, 2 percent, with aloes, 
rhubarb, camphor and several aromatic herbs. 
Dose, 1 ounce (about 9 1/2 grains of quinin bi- 
sulphate) in 2 doses given 3 hours apart. Hager's 
modification of the original formula is-quinin 
sulphate 1, Spt. camphorse 2, Tinct. aloes et 
myrrhse 22, alcohol 16. Dose, as above. Some 
of the preparations now sold under this name con- 
tain few, if any, of the original ingredients. The 
so-called Warburg's Pill is a most irrational form 
in which to administer this complex medicine, 
even if it contains the proper constituents. See 
Cinchona, Euquinin. 
QUININ HYDROCHLORID AND UREA.- 
Quinin carbamid hydrochlorid or urea-quinin. 
Recently this drug has been highly recommended 
as a local anesthetic in operations on the nose and 
throat and in ano-rectal surgery. A 1 percent 
solution is injected locally or a 10 to 20 percent 
solution is applied locally to the mucous mem- 
branes. The resulting anesthesia is claimed to be 
considerably prolonged. As a palliative measure a 
20 percent solution has been applied in tuberculous 
ulcers of the larynx with excellent results. Quinin 
hydrochlorid and urea has also been used with good 
effect in hydrophobia. An intravenous injection of 
15 grains of the drug in 3 c.c. of normal saline solu- 
tion is used. This is twice repeated at intervals of 
two hours. More injections may be used if neces- 
sary, but the intervals between injections must be 
greatly increased. 
QUINSY.-See Tonsillitis. RABIES 
RAILWAY INJURIES 
R 
RABIES.-See Hydrophobia. 
RACHITIS.-See Rickets. 
RADIOTHERAPY.-See Radium. 
RADIUM.-Radium is one of the newer ele- 
ments. It is a radioactive substance, obtained 
from pitch blende, and discovered by Madame 
Curie and her husband in 1898. It is of high 
atomic weight; extremely rare and expensive, 
being almost unobtainable in the pure state. It 
is of interest because of its wonderful radioactive 
emanations. These are of three kinds, and are 
designated as the Alpha, Beta, and Gamma rays. 
The Alpha rays have very slight penetrating quali- 
ties and are chiefly or entirely absorbed by the con- 
tainer. The Beta rays are the most numerous and 
have only a moderately penetrating effect, being ab- 
sorbed chiefly by the skin and subcutaneous tissue. 
The Gamma rays, on the other hand, correspond 
rather closely to the Roentgen rays, and are very pen- 
etrating, probably more so than the Roentgen rays. 
Therapeutically its exact value has not yet been 
dptermined, but it has been used successfully in 
the treatment of various obstinate skin diseases, 
such as epithelioma, rodent ulcer, and nevus. It 
has also been used with some degree of success in 
the treatment of deep-seated malignant disease, 
particularly when located in the cavities, which 
are not easily reached by the Roentgen rays. 
It is used as a paste for external applications or 
in tubes. These tubes are often introduced into 
cavities; or even, by surgical means, into the 
tumors themselves. 
RADIUS.-See Forearm. 
RAILWAY INJURIES.-These are of greatest 
interest from their medicolegal aspect. Trivial 
railway injuries might be immediately followed by 
loss of memory, defective sight, pain in the back, 
and the usual symptoms of nerve shock, and sub- 
sequently by the most formidable array of nervous 
symptoms. On the other hand, very severe 
injuries may be followed by prompt and complete 
recovery. The more serious results are dependent 
upon the great weight and impulse of the train, 
the sudden arrest of momentum, and direct trau- 
matism. Serious spinal injuries and violent shock 
have occurred to persons sitting in a train not in 
motion that has been struck by a moving train 
from behind. It is the sudden and violent 
character of the occurrence, the alarm and fright, 
the general jar and commotion of the whole body, 
and possible local damage that make the main 
features of railway injuries. 
Direct results of railway accidents are various, 
but ligamentous lesions are perhaps the most 
characteristic. Death has resulted from sheer 
fright. The indirect results are also numerous 
and varied. It must always be borne in mind that 
a chronic inflammation may be lighted up by an 
accident; syphilitic, gouty, tubercular, and even 
cancerous diseases may follow and complicate 
the symptoms arising from the injury. Chronic 
inflammatory conditions of the cord or its mem- 
branes may be induced. Certain indefinite phe- 
nomena constantly render the diagnosis and prog- 
nosis of railway injuries difficult. When no local 
lesion of importance exists, neurasthenic condi- 
tions are likely to occur which are doubtless ex- 
pressions of an exhausted nervous system. The 
temperature in these cases is often subnormal and 
the pulse slow. Asthenopia, with difficulty in, 
or real loss of the power of, accommodation, may 
impair the vision. Physical changes in the ret- 
ina and optic disc are extremely uncommon, and 
generally follow organic lesions of the spinal cord 
and membranes. Functional disturbances, prob- 
ably of cerebral origin, are often added to this 
neurasthenic condition, and in such cases there are 
frequently medicolegal controversies. The com- 
mon "railway spine" is considered under the head 
Spinal Cord (Injuries) (q. v.). 
Every medical attendant, as well as medical 
officer of any railway, should familiarize himself 
with all the circumstances of an accident and its 
results. Apart from the accident itself, the 
approximate speed of the train, the position of 
patient in the carriage and of carriage in the train, 
the presence of other uninjured passengers, the con- 
dition from the time of the accident to the time of 
examination, and the symptoms complained of, 
should be noted fully and filed away for reference. 
The general condition of the patient, especially as 
to appetite, capacity for work or sleep, and pre- 
vious habits, the possible existence of organic dis- 
ease, and the condition of urine are to be investi- 
gated. Bruises or signs of local injury are to be 
noted, and when injury to the spine is alleged, the 
amount of mobility or rigidity noticed when 
undressing, the effects of digital pressure or per- 
cussion, and the application of hot or cold sponges 
should be noted. The circumference of limbs 
should be measured, the electric excitability of 
muscles tested, the existence of spasm or tremor 
and the condition of reflexes, superficial and deep, 
ascertained. Cutaneous sensibility should be in- 
vestigated, and an ophthalmoscopic examination 
may be made to determine the existence of local 
lesions of the fundus. 
The medical attendant should form an opinion 
on the following points: Has the patient been 
really injured ? What is the nature of the injury ? 
Is the injury a possible or probable result of the 
accident as described ? Are the symptoms consis- 
tent with the history and objective signs? 
Railroad surgeons are usually given sufficient 
directions by the corporation that employs them, 
according to the views of their chief officers or in 
compliance with the law prevailing in the district 
where such accidents may occur. RAILWAY INJURIES 
RALES 
The treatment of railway accidents is mostly 
surgical, and differs in no way from the treat- 
ment of similar injuries received in other ways, 
and which are fully discussed in other portions 
of the book under their various headings. Im- 
mediate treatment, even by the train crew and 
passengers, is necessary. Hemorrhage should be 
prevented by the prompt application of pressure. 
A handkerchief, belt, or suspender tied around a 
limb or twisted tight by a stick, or direct pressure 
with the finger, will usually suffice. 
Fractures should be placed in improvised splints 
from umbrellas, walking-sticks, cushions, news- 
papers, broken pieces of wood, etc., and fixed by 
straps or suspenders, handkerchiefs, etc. 
Simple dislocations should be reduced as early 
as possible, and simple fractures prevented from 
becoming compound. 
Shock, collapse, and fright require great cau- 
tion to maintain the vital powers until reaction 
sets in. The temperature of the body, the strength 
and rate of the heart's action, together with the 
respiration, are to be maintained by external 
warmth and by internal stimulants. Overstimu- 
lation is also to be guarded against. See Col- 
lapse, Shock. 
Exposure to cold and wet should be prevented 
and shelter provided as soon as possible, followed 
by early removal to a hospital or place of rest. 
Subsequent treatment of railway injuries requires 
absolute rest for a long time, especially if spinal 
lesions are suspected; change of scene and mode- 
rate exercise often are beneficial, especially when 
neurasthenic conditions supervene. See Abdo- 
men (Injuries), Chest (Injuries), Fractures, 
Spinal Cord (Injuries), Spine (Injuries), etc. 
RAILWAY SPINE.-See Spinal Cord (In- 
juries). 
RALES.-The sounds caused by the breaking 
of air through impediments or passing over ob- 
structions in the lungs and bronchi. They vary in 
character according to the consistency of the sur- 
rounding lung tissue. Sometimes a distinction is 
made between rales and rhonchi. The first word 
is applied to sounds generated by vibrations set up 
in fluids; the second, to sounds generated in the 
narrowed or obstructed lumen* of tubes. See 
Chest (Examination). 
RALES, TABLE OF. 
Variety. 
When Heard. 
How and Where Produced. 
Size and Character. 
Condition in Which 
Heard. 
Amphoric 
Inspiration and ex- 
piration. 
By movement of air in a tense- 
walled cavity containing air and 
communicating with a bronchus. 
Large, musical, and 
tinkling. 
In tuberculous and abscess 
cavities. 
Bubbling, 
large. 
Inspiration and ex- 
piration. 
By passage of air through frothy 
mucus in the trachea and larger 
bronchi. 
Larger than the me- 
dium bubbling; moist. 
Bronchitis and pulmonary 
engorgement. 
Bubbling, me- 
dium. 
Inspiration and ex- 
piration. 
By passage of air through mucus 
in the larger tubes. 
Larger than the small 
bubbling; moist. 
In capillary bronchitis 
especially in children. 
Bubbling, 
small. 
Inspiration and ex- 
piration. 
By passage of air through mucus 
in the bronchioles. 
Small; moist; like the 
bursting of soft bub- 
bles. 
In capillary bronchitis, 
especially in children. 
Cavernous.... 
Inspiration and ex- 
piration. 
By passage of air through a small 
cavity with flaccid walls, which 
collapse with expiration. 
Hollow and metallic.... 
In the third stage of pul- 
monary tuberculosis. 
Clicking 
Inspiration only.... 
By passage of air through soften- 
ing material in smaller bronchi. 
Small; sticky 
The apex in pulmonary 
tuberculosis. 
Consonating... 
Inspiration and ex- 
piration. 
When bronchial tubes surrounded 
by consolidated tissue. 
Bright, clear, ringing... 
Tuberculous pneumonia. 
Crackling, dry. 
In inspiration 
By the breaking down of lung 
tissue. 
Sharp, short, and click- 
ing. 
In the second or softening 
stage of pulmonary tuber- 
culosis and in pulmonary 
gangrene. 
Crackling, 
large. 
Inspiration and ex- 
piration. 
By fluid in very small cavities... 
Larger than the me- 
dium crackling; dry. 
In pulmonary tuberculosis 
and pneumonia, after for- 
mation of small cavities. 
Crackling, 
medium. 
Chiefly in inspira- 
tion. 
By fluid in the finer bronchi 
Larger than the small 
crackling; dry. 
Softening of tuberculous 
deposit or pneumonic 
exudation. 
Crackling, 
small. 
Chiefly in inspira- 
tion. 
By fluid in the finer bronchi 
Small; dry; like the 
breaking of small 
shells. 
Softening of tuberculous 
deposit or pneumonic 
exudation. 
Crepitant 
End of inspiration 
only. 
By passage of air into vesicles col- 
lapsed, or containing fibrinous 
exudation. Usually at the base 
of the lungs. 
Small; like rubbing the 
hair between the fingers. 
Pneumonia, early stage; 
edema of lungs; hypo- 
static pneumonia; local- 
ized in pulmonary tuber- 
culosis. RANULA 
RAPE 
RALES, TABLE OF 
Variety. 
When Heard. 
How and Where Produced. 
Size and Character. 
Condition in Which 
Heard. 
Dry 
Inspiration and ex- 
piration. 
By narrowing of the bronchial 
tubes from thickening of the 
mucous lining, from spasmodic 
contraction of the muscular coat, 
viscid mucus within, or pressure 
from without. 
Large and sonorous, or 
small and hissing, or 
whistling. 
In bronchitis, asthma, and 
localized in beginning 
pulmonary tuberculosis. 
Extrathoracic. 
In the trachea or larynx. 
i 
Friction 
Inspiration and ex- 
piration ; most dis- 
tinct at the end of 
inspiration. 
By the rubbing together of serous 
surfaces, roughened by inflam- 
mation or deprived of their nat- 
ural secretion. 
Grazing, rubbing, grat- 
ing, creaking, or crack- 
ling. 
In pleurisy and pericar- 
ditis. 
Gurgling 
Inspiration and ex- 
piration. 
By the passage of air through 
fluid in cavities, on coughing. 
Larger than the large 
bubbling; moist; like 
the bursting of large 
bubbles. 
Pulmonary tuberculosis, 
after formation of cavi- 
ties. 
Guttural 
In the throat. 
Moist 
• 
By the passage of air through 
bronchi containing fluid. 
Mucous (of 
Laennec). 
Inspiration and ex- 
piration. 
By viscid bubbles bursting in the 
bronchial tubes. 
A modification of the 
subcrepitant. 
Pulmonary emphysema. 
RMe redux, 
rMe de retour. 
Inspiration and ex- 
piration 
By the passage of air through 
fluid in a bronchial tube. 
Crackling and unequal.. 
In pneumonia in the stage 
of resolution. 
Sibilant 
Inspiration and ex- 
piration. 
By narrowing of the smaller 
bronchi from viscid mucus ad- 
hering to the walls, from thick- 
ening of the lining membrane 
or spasmodic contraction. 
High-pitched and even 
hissing or piping. 
In bronchitis, asthma, and 
localized in beginning 
pulmonary tuberculosis. 
Sonorous 
Inspiration and ex- 
piration. 
By lessened caliber of the larger 
bronchi, from spasm, tumefac- 
tion of mucous lining, or external 
pressure. 
Low-pitched and snor- 
ing. 
Most frequent in bronchitis 
and spasmodic asthma, 
but may occur in any pul- 
monary disease. 
Subcrepitant.. 
Inspiration and ex- 
piration. 
By passage of air through mucus 
in the capillary bronchial tubes. 
Small; moist 
Capillary bronchitis 
Subcrepitant 
(of Hirtz). 
Inspiration and ex- 
piration. 
By passage of air through mucus 
in the capillary bronchial tubes. 
Moist; metallic 
Tuberculous softening. 
RANULA.-A cystic tumor beneath the tongue, 
connected with the duct of the sublingual salivary 
gland. 
Varieties.-True ranula, found in the floor of 
the mouth, from the size of a walnut to a pigeon's 
egg, and containing glairy, tenacious contents. 
Mylohyoid, found between the mylohyoid and 
buccal mucous membrane, often as large as an 
orange, and filled with cheesy contents. 
Etiology.-The common form of ranula has thin 
walls, and contains a fluid somewhat resembling 
saliva, and hence formerly supposed to be a dilata- 
tion of the duct of the submaxillary gland. It 
may be that this is true in those instances in which 
the duct is occluded by a salivary calculus, but in 
the majority of cases the ranula appears to be a 
distinct cyst. 
Symptoms.-If the ranula has attained some 
size before it is noticed, it may be large enough to 
crowd the tongue against the hard palate, so that 
swallowing is interfered with, and sometimes 
even breathing becomes difficult, especially if 
there is concomitant coryza; or there may be 
convulsive attacks of dyspnea, simulating croup. 
Prognosis is favorable, though the disease is 
prone to recur; rarely spontaneous cures have 
been known to follow suppuration. 
Treatment.-If complicated with croupy at- 
tacks, the following operation should be imme- 
diately performed: Open the sac sufficiently to 
cauterize thoroughly its inner walls, which must 
be repeated often enough to prevent union, except 
from the bottom of the sac. If this is not obtained, 
relapses will occur. 
RAPE.-The carnal knowledge by a boy or 
man of a female forcibly and unlawfully and 
without her conscious and free consent. If a 
woman is incapable of giving consent, as in idiocy, 
imbecility, or any mental unsoundness, either 
temporary or permanent, sexual intercourse with 
her is rape. If at the time of the act the victim 
is unconscious of the nature of the act, and this 
fact is known to the defendant; if her resistance 
is forcibly overcome or prevented by fear of im- 
mediate and great bodily harm, which she has 
reason to believe will be inflicted upon her; or if 
she is prevented from resisting by stupor or mental 
weakness produced by intoxicating, narcotic, or RAPE 
RAYNAUD'S DISEASE 
anesthetic agents administered by or with the 
privity of the person accused of the crime, the 
offense constitutes rape. It is immaterial whether 
the victim is a virgin or a common prostitute. 
Age of consent is the age below which a female 
is incapable of giving legal consent to sexual con- 
nection, and such connection on the part of a man 
is rape, in spite of her consent or desire. 
The age of consent in the various States is given 
in the following table (compiled by the New York 
Society for the Prevention of Cruelty to Children):- 
table in Ohio, Massachusetts, New York, and 
Tennessee. 
A boy under 14 cannot be convicted of rape in 
California, but in North Carolina and Florida 
courts the English law is followed. In Louisiana 
there is no foundation for the presumption of 
incapacity. Here the law conforms to the medical 
knowledge. It is not essential to prove emissions, 
as mere touching of the vulva by the penis suffices 
to establish the fact of carnal knowledge. 
If the victim is under years of discretion, her 
evidence, even when unsupported, if believed by 
the jury sufficient to leave no reasonable doubt 
of guilt, will justify a conviction. 
It is a matter of doubt whether rape is possible 
upon a woman of fair size and strength when com- 
mitted by an unaided man. If in the enjoyment of 
her faculties, she is capable of offering an amount of 
resistance well-nigh insuperable, and if she has 
offered a decent resistance, the person of the 
ravisher should bear evidence of it. Rape is 
most often committed on children of tender-years, 
but it is well to be on one's guard against error. 
Purulent discharges from the vagina are not un- 
common in ill-fed, dirty, and scrofulous children. 
The medical evidence is based on: (1) Marks of 
violence about the woman's genital organs; (2) 
wounds, bruises, or other marks of injury on the 
woman or on the accused; (3) blood stains and 
seminal stains on the person or clothing of either 
party; and (4) the presence of any venereal disease 
on either party. 
For examination for spermatozoa, see Seminal 
Stains. 
RASH.-See Exanthems, Skin-diseases. 
RATION, EMERGENCY.-One with high force- 
value and with sufficient available nitrogen for the 
needs of hard labor, prepared in compact form and 
designed for occasions when the use of the regular 
ration is impracticable. 
State. 
Age of Consent. 
12 
14 
15 
16 
Alabama 
14 
Arkansas 
16 
California 
16 
Colorado 
16 
Connecticut 
16 
Delaware 
18 
Florida 
Georgia 
14 
Idaho 
18 
Illinois 
16 
Indiana 
16 
Iowa 
15 
Kansas 
18 
Kentucky 
16 
Louisiana 
18 
Maine 
16 
Maryland 
16 
Massachusetts 
16 
Michigan 
16 
Minnesota 
16 
Mississippi 
14 
Missouri 
18 
Montana 
18 
Nebraska 
18 
Nevada 
18 
New Hampshire 
16 
New Jersey 
14 
New York 
18 
N. Carolina 
14 
N. Dakota 
16 
Ohio 
- . 
16 
Oklahoma 
16 
Oregon 
16 
Pennsylvania 
16 
Rhode Island 
16 
S. Carolina 
14 
S. Dakota 
16 
Tennessee 
Texas 
15 
Utah 
18 
Verm on t 
16 
Virgina 
12 
Washington 
16 
W. Virginia 
Wisconsin 
18 
Wyoming 
18 
UNITED STATES ARMY EMERGENCY 
RATION. 
Quan- 
tity (in 
Ounces) 
Pro- 
tein 
(Grams) . 
Fats 
(Grams). 
Carbo- 
hy- 
drates 
(Grams). 
Full 
Value 
(Cal- 
ories). 
Hard bread, 
Bacon, 
Pea meal, 
Coffee, roast- 
ed and 
g r o u n d, 
with fo u r 
grains of 
saccharin, 
Or tea, with 
four grains 
of saccha- 
rin, 
Salt, 
Pepper, 
Tobacco, 
16. 
10. 
4. 
2. 
.5 
.64 
.04 
.5 
70.76 
24.94 
24.94 
5.89 
218.14 
2.25 
332.94 
59.84 
1.712 
2.030 
.368 
33.68 
126.64 
226.28 
392.78 
4.110 
Indecent assault may include various factors of 
an attempt to commit rape, comprising, in the 
case of a child, putting the hands on the external 
genitals or even feeling the legs. 
Legal rape may be committed only when there 
is physical capacity in the direct perpetrator. A 
boy under 14 cannot commit rape according to 
the law in some countries and States, and no evi- 
dence is admissible if he is under that age, even 
though the fact could be shown that he had ca- 
pacity. The presumption of capacity is rebut- 
RAY FUNGUS.-See Actinomyces. 
RAYNAUD'S DISEASE (Symmetric Gangrene; REACTION OF DEGENERATION 
RECTUM, EXAMINATION 
Sphaceloderma).-A rare disease, characterized 
by a local stagnation occurring at the periphery 
of the circulation, producing symmetrically dis- 
tributed gangrenous spots on the body. The 
disease occurs in 3 well-defined grades, which are, 
in the order of severity, local syncope, local as- 
phyxia, and local gangrene. The so-called "dead 
finger," frequently seen in females, is an example 
of the first grade. 
Local syncope is observed most frequently in the 
extremities, and produces the condition known 
as dead fingers or dead toes; it is analogous to that 
induced by intense cold. 
Local asphyxia, which usually follows local syn- 
cope, but may develop independently. Chilblains 
are the mildest manifestation of this condition. The 
fingers, toes, and ears are the parts usually affected. 
In the most extreme degree the parts are swollen, 
stiff, and livid, and the capillary circulation is 
almost stagnant. 
Local or Symmetric Gangrene.-The mildest 
form follows local asphyxia. Small areas of ne- 
crosis appear on the pads of the fingers and of the 
toes, also at the edges of the ears and tip of the 
nose. Occasionally, symmetric patches appear 
on the limbs or trunk, and in severe cases ter- 
minate in extensive gangrene. 
Raynaud suggested that the local syncope is pro- 
duced by contraction of the vessels; the asphyxia 
is probably caused by dilatation of the capillaries 
and venules, with persistence of the spasm of the 
arterioles. The condition is probably due to some 
disturbance of the vasomotor nerve-center or in 
some instances to a peripheral neuritis. Two 
forms of congestion occur, which may be seen in 
adjacent fingers, one of which may be swollen, in- 
tensely red, and extremely hot; the other swollen, 
cyanotic, and icy cold (Osler). 
Pain is the most prominent symptom of the 
disease, which usually attacks children or adults 
under 30 years of age. Women of the neurotic 
temperament are more liable to be affected, and 
especially does it occur after some sudden mental 
shock. The disease is frequently associated with 
hemoglobinuria. Scleroderma and edema, prob- 
ably angioneurotic, may be observed. There may 
also be cerebral symptoms, impaired vision, arth- 
ritic swelling, tingling and formication due to 
peripheral neuritis. 
Treatment.-When seen early, galvanism, with 
one electrode applied to the spine and the other 
immersed with the affected part in water, is the 
best treatment. Friction with stimulating lini- 
ments, as for frost-bite, is also of value. Nitro- 
glycerin is highly recommended. See Gangrene. 
REACTION OF DEGENERATION.-See Degen- 
eration (Reaction), Nervous Diseases (Exam- 
ination) . 
RECTOCELE.-Protrusion of the anterior wall 
of the rectum and posterior wall of the vagina into 
the vagina or through the vaginal ostium. The 
condition is due to injury of the perineum that 
takes away the support of the posterior vaginal 
wall. The bulging of the vaginal wall causes a 
distinct tumor, which is readily recognized on 
separation of the vulva. Straining or bearing- 
down efforts cause an increase in the size of the 
tumor. The patient feels during defecation as 
though the feces were about to pass through the 
vagina. Pressure on the rectocele will easily 
replace it. 
The treatment of rectocele consists in repair of 
the perineum by Emmet's operation. See Peri- 
neum. 
RECTOVAGINAL FISTULA.-See Vaginal 
Fistula. 
RECTUM, ABNORMALITIES.-The only con- 
genital malformation needing mention here is im- 
perforate anus. The anus may be entirely absent; 
it may be present but separated from the rectum 
by a membrane; or the rectum may open into the 
bladder, prostatic urethra, or vagina. 
Treatment.-When only a thin membrane inter- 
venes, its division is all that is necessary. When 
there is no apparent outlet to the rectum, careful 
dissection is made upward to the bowel from a 
spot where the rectum is normally situated. 
Mayo Robson advises continuing the dissection in 
the perineum, opening the peritoneum, pulling the 
end of the gut down and fixing it to the skin. In 
some cases left inguinal colotomy is necessary. 
See Anus (Preternatural). 
RECTUM, ADMINISTRATION OF MEDICINE 
BY.-See Medicines (Administration). 
RECTUM, EXAMINATION. Interrogation.- 
After the patient has concluded the description of 
the ailment, the following are the principal queries 
which may be asked with advantage (Adler): 
1. In Reference to Pain.-Is there any pain? 
If so, of what character? Is it situated in the 
rectum? What is its relation to the act of defeca- 
tion? Is it worse during an evacuation, shortly 
afterward, or some time after the movement? Is 
itching, a sense of fullness, or heat experienced? 
2. Regarding Protrusion.-Is there any swelling 
or protrusion at the anus? Does this occur only 
at defecation, or is it independent of this act? 
Does it bleed? Does it go back spontaneously, or 
has the patient to return it? 
3. As to the Presence of a Discharge.-Is there 
any discharge? If so, what is its nature (bloody, 
mucous, or purulent)? Is it offensive? Does it 
occur before or immediately after defecation, or is 
it independent of the action of the bowels? 
4. As to the Regularity of the Action of the 
Bowels.-Is there a daily movement, or does con- 
stipation or diarrhea exist? What is the charac- 
ter of the fecal evacuation as to color, size, and 
consistence? 
5. General Interrogations.-Does the patient 
cough, have night-sweats, spit blood, or has there 
been a loss of flesh? What are the habits of life, 
especially with reference to the use of alcoholic 
liquors, tobacco, and to indulgence in venery? 
Is there any specific history? Lastly, inquire as 
to any hereditary tendency to rectal trouble, 
malignant disease, kidney, liver, or heart affection. 
In women inquire into the condition of the sexual 
organs, etc. Whenever the idea of any operative 
procedure is entertained, the urine should be exam- 
ined, and a thorough physical inspection of the 
patient made. RECTUM, EXAMINATION 
RECTUM, EXAMINATION 
Having obtained the subjective symptoms and 
being satisfied as to the existence of rectal disease, 
we proceed to confirm the provisional diagnosis 
and to obtain positive information upon which to 
base the prognosis and to guide the treatment by 
making a thorough local examination. If possible, 
the patient should have the bowel emptied by an 
enema immediately before an examination is 
attempted. In the case of female patients 
especially the neglect of this will often render a 
thorough investigation impossible, without re- 
course to anesthesia, owing to the fear of an acci- 
dent occurring-such as the escape of flatus. 
Under such circumstances the sphincter muscles 
may be so tightly closed that the surgeon is 
frustrated in the attempt to explore the parts. 
When a specular examination is necessary, as in 
the case of an investigation of the higher portions 
of the rectum or of the sigmoid flexure, it is 
absolutely essential that the contents of the 
bowel are removed. 
Postures.-There are various postures in which 
this examination may be made. Some surgeons 
prefer the patient to lean over the back of an or- 
dinary chair; others, to have them kneel upon a 
table with the head of the patient placed on his 
folded arms, by which means the buttocks are 
elevated and the intestines are allowed to gravitate 
from the seat of investigation; others, the lithot- 
omy position; but for general use Adler thinks 
that the most comfortable as well as the most 
delicate posture for the patient, and that most con- 
venient for the examiner, is for the patient to lie 
on a firm couch on the left side, the right shoulder 
turned away from the surgeon, the left arm 
brought behind the body, and the right thigh well 
flexed upon the abdomen. In examining for the 
presence of strictures or growths situated above 
the lower 4 inches of the rectum, by directing the 
patient to stand and strain, the diseased part will 
be brought nearer to the anus, so that at least an 
inch or more of the bowel may be explored than 
can be done when the patient assumes the usual 
position, even though directions are given to bear 
down. 
Light.-Either natural or artificial light may be 
used. By means of a head-mirror (the operator 
sitting facing the light and the patient's back 
being from the same) the light may be concen- 
trated upon any particular point requiring observa- 
tion. 
The instruments usually required are: A flexible 
probe made of silver, useful for the exploration of 
fistulous tracks; an exploring needle, or a small 
trocar, by means of which can be ascertained the 
nature of the contents of any swelling or fluid col- 
lection; Kelly's short and long proctoscope and 
his sigmoidoscope; sponge-holders; basins; and 
possibly a hypodermic syringe, with a flexible sil- 
ver cannula attached, which is useful in detecting 
whether a fistula is complete or otherwise. Plenty 
of towels and cotton should be on hand. 
** Inspection of the Condition of the External 
Parts.-On separating the buttocks, the orifice of 
the anus will come into view. The radiating folds 
should be separated by the fingers, and cracks, 
excoriations, and fissures should be looked for. 
External hemorrhoids will also be noted, if 
present. By passing the finger around the anus 
and making pressure, any induration that exists 
will be detected; this may be due to a fistula or an 
abscess. If the parts are covered with a discharge, 
it should be wiped away and its source traced, as to 
whether it is from an external opening of a fistu- 
lous track, etc. Eruptions of any kind-eczemat- 
ous, syphilitic, or otherwise-must also be noticed. 
Digital Examination of the Interior of the Rec- 
tum.-The method of making the examination is as 
follows (Adler): The nail of the index-finger, being 
well-trimmed and the finger lubricated with car- 
bolized linseed oil, is introduced into the bowel by 
a slow boring motion, in a direction at first slightly 
forward. This should be done gradually, so as to 
allow the sphincters time to relax; if attempted too 
hurriedly or in too forcible a manner, spasm of 
the muscles will to a certainty be induced. As the 
finger enters, the condition of the sphincters is 
noted. The strength, measured by the power of 
resistance, will be found to vary greatly in different 
people. In the aged or debilitated it is likely to be 
very weak; and just the reverse in the strong and 
healthy. In persons of a specially nervous tend- 
ency and in cases of irritable ulcer of the anus, a 
contraction may be met with, which, owing to the 
pain, will render an examination impossible with- 
out the use of an anesthetic. 
The finger should now be passed its full length 
up the bowel, unless an obstruction exists, and by 
instructing the patient to bear down forcibly the 
rectum can be explored for a considerable distance. 
Additional length may be gained by passing the 
other fingers of the examining hand backward 
along the intergluteal groove, instead of closing 
them in the palm, as is generally done, and pressing 
the knuckles against the soft parts. The knuckles, 
in the latter procedure, prevent the full passage of 
the index-finger. In this manner about 3 1/2 or 
4 inches of the rectum may be explored, together 
with the prostate, the neck of the bladder, the 
uterus, the anterior surface of the coccyx and the 
lower part of the sacrum, the ovaries and tubes, 
and the broad ligament. With an exceptionally 
long finger it may be possible to feel the seminal 
vesicles and the vasa deferentia. 
In making an examination of the rectum it must 
be borne in mind that frequently two or more 
rectal affections coexist: as, for instance, a polypoid 
growth complicating a fissure, or malignant disease 
existing with fistula and hemorrhoids, etc. 
Malignant infiltration, or stricture, can be 
detected if situated within reach. By sweeping 
the finger around the mucous membrane, its con- 
dition can be noted: a general smoothness, and 
absence of the normal folds indicating atony; ulcer- 
ation can be recognized, and the attachment of 
polypi can be felt. In examining for a polypus 
it is important that the finger should be brought 
from above downward; as otherwise the growth 
may be pushed out of reach owing to the length of 
the pedicle, which is often considerably elongated. 
Fecal masses in the rectal pouch can be recognized 
without difficulty. RECTUM, EXAMINATION 
RECTUM, INFLAMMATION 
The finger is now to be partly withdrawn, pass- 
ing the palmar surface around the entire surface of 
the mucous membrane as this is done, in order to 
note the existence of internal openings of fistulse, 
the seat of ulcers, etc. As the outlet of the bowel 
is approached, internal piles may be perceived; 
but the fact should always be remembered that 
unless they are thickened by inflammatory changes 
they are extremely hard to recognize by the touch; 
in point of fact, the sensation conveyed to the 
finger is more apt to deceive the surgeon than any 
other rectal trouble. 
The Use of the Speculum.-In the large majority 
of rectal diseases digital and ocular examination is 
sufficient for purposes of diagnosis; but for some 
cases the use of the speculum is desirable. This 
instrument is made in a variety of forms; the length 
of the tube to be selected depending on the portion 
of the bowel to be explored. Before being intro- 
duced into the rectum the speculum should be 
warmed and well-lubricated; it should then be 
inserted into the anus, and gently but slowly 
directed a little forward and upward for a distance 
of about an inch, as if to pass from the perineum 
to the umbilicus, in order that it may follow the 
course of the anal canal; having reached this depth, 
which is somewhat greater in the male than in the 
opposite sex, the point should be inclined back- 
ward, first slightly, and afterward to a greater 
extent, until the instrument is fully inserted. 
Should the interior view of the rectum be ob- 
structed by blood, mucus, or feces, a mop of cot- 
ton attached to a holder, made for the purpose, 
should be used to cleanse the parts. With these 
instruments the interior of the rectum and the 
sigmoid flexure can be examined, and the exact 
condition of affairs ascertained. Some forms of 
speculum are furnished with blades or plates, which 
can be separated to the requisite extent by means 
of a screw attachment. 
The use of the rectal bougie for diagnostic pur- 
poses Adler condemns. The introduction of these 
instruments is one of considerable difficulty, and 
requires greater practice than the passage of a 
urethral catheter; the danger of perforation is as 
great, and the result of such an accident is very 
much more serious, than in the urethra. In one 
case a fatal peritonitis will likely be started, while 
in the other a false passage will probably be the 
sequence. The use of the Kelly tube has obviated 
the necessity of employing the rectal bougie for the 
purpose of diagnosis. 
Rectal Eversion as a Means of Diagnosis.-In ex- 
amining the rectum in females, Stover has recom- 
mended eversion of the bowel by the fingers placed 
into the vagina. This method is useful in women 
who have borne children, but not in the young and 
unmarried. A portion of the anterior wall may 
thus be exposed. 
The introduction of the hand into the rectum is a 
procedure which may be a means of exploration 
open to the surgeon, but it is doubtful if the 
amount of information obtainable by its use is 
sufficient to warrant the practice. 
Exploration with a silver probe 7 or 8 inches in 
length is of value in detecting blind, external, inter- 
nal, or complete anal fistula. Being flexible, it 
may be bent to any desired form. 
Injections of various fluids, such as peroxid of 
hydrogen, a 2 percent solution of creolin, milk, or 
a weak iodin solution, often serve a useful purpose 
for detecting the internal opening of a fistulous 
tract. 
RECTUM, INFLAMMATION (Proctitis).- 
Catarrhal inflammation of the mucous membrane 
may arise from various causes: Gonorrheal infec- 
tion, especially in women; syphilis during the 
secondary stage; abuse of purgatives; gout; errors 
in diet, etc. Except when it is due to the first 
of these, it is rarely severe; there is a sense of 
heat and weight in the perineum, with a constant 
desire to defecate. The sphincter is in a state of 
painful spasm; the anus is hot and tender; the 
amount of mucus is increased, and this, escaping 
externally, leads to excoriation and perhaps super- 
ficial ulceration. As a rule, the symptoms subside 
as the cause is removed; sometimes, however, 
they become chronic; and occasionally, when 
severe, painful catarrhal ulcers develop, requiring 
special treatment. 
Ulceration of the rectum is much more serious, 
not only for itself but from the way in which it 
leads to stricture and fistula. In some cases it is 
the result of injury, the introduction of foreign 
bodies, the use of enema tubes, or the passage of 
hard scybalous masses, especially as the circulation 
is often sluggish and the tissues badly nourished 
from the presence of varicose veins. In others 
it arises directly from thrombosis and inflammation 
of the veins, or from dysentery involving the rec- 
tum as well as colon. When this occurs, the 
ulcers formed are of a peculiarly irregular charac- 
ter; they spread in all directions, forming little 
islands, which, as cicatrization takes place, stand 
out as hard warty excrescences; or they undermine 
the mucous membrane, so that it leaves rigid cords 
passing across the interior from one part to an- 
other; and the scars are of such extreme density 
that not improbably many of them have been 
mistaken for scirrhus. 
In other cases ulceration is due to syphilis. In 
its earlier stages this attacks the anus chiefly; con- 
dylomata and superficial sores occur around the 
margin, leaving irregular folds of skin between 
which are painful fissures, not unlike those at the 
angles of the nose and mouth. In the latter it 
breaks out on the mucous membrane, some 
distance from the anus, forming deep serpiginous 
sores, which may extend almost around the bowel. 
Tubercle is still more common, beginning in the 
adenoid tissue between and beneath the follicular 
glands. Little nodules make their appearance 
first, not larger than millet seeds, and only slightly 
raised above the surface; after a time these become 
caseous and break down, leaving shallow depres- 
sions, w'hich grow larger and deeper, until at length 
they become circular sores with overhanging edges. 
In other cases the caseous deposit seems to infil- 
trate the adenoid tissue in the mucous and sub- 
mucous layers before the surface gives way, and 
deep, irregular ulcers are formed, which almost at 
once become the orifices of tuberculous fistulae. RECTUM, INFLAMMATION 
RECTUM, INFLAMMATION 
Ulceration somewhat similar in character is not 
infrequently associated with albuminuria; prob- 
ably it originates as catarrhal inflammation; after 
a time the lymphatic follicles become affected and 
break down; and then, as there is no longer any 
protection against septic infection, the deeper 
tissues become inflamed as well. In many cases it 
is difficult to distinguish this from the preceding; 
they both occur in patients whose health has failed 
and whose tissues are badly nourished; and they 
both lead to ulceration, and not infrequently to 
fistulous channels of very much the same descrip- 
tion. In addition to these lupoid ulceration may 
attack the skin around the anus and the mucous 
membrane of the rectum. It is essentially destruc- 
tive in character, and cicatrization is unusual. 
The edges and base are not hard, as in malignant 
disease; and the former are undermined and 
overhanging. Sometimes it remains stationary 
for a time, and is apparently beginning to heal; 
then it all breaks down again. It is only met with 
in tuberculous subjects, and probably is itself 
tuberculous. The only treatment that has proved 
of any use is scraping and the actual cautery; 
sometimes the pain, at least, can be relieved in 
this way for a time. 
Symptoms.-In acute inflammation of the rec- 
tum the patient complains of a sense of heat and 
weight in the perineum, spreading over the back 
and thighs, and of violent straining and spasm of 
the sphincter. The skin is dry and feverish; the 
anus is very tender; the finger, if it is introduced, is 
tightly gripped; and the mucous membrane feels 
burning hot. In severe cases the constitutional 
symptoms are very marked; the pain radiates over 
the whole of the lower part of the body, and there 
is nearly always retention of urine. 
The symptoms of ulceration depend upon its 
situation. When the anal margin is involved, 
they are so striking and so severe that this affection 
is described as fissure of the anus (see Anus (Fis- 
sure)); when, on the other hand, they are higher 
up-above the level of the external sphincter- 
they are at first very vague. Diarrhea is the 
most prominent; as soon as the patient gets out of 
bed there is an immediate desire to go to the closet, 
and a small quantity of liquid feces, with some 
mucus like white of egg, comes away. The same 
thing occurs perhaps once or twice in the morning; 
and then, if the ulceration is not far advanced, the 
rest of the day is passed in comparative comfort; 
the rectum is empty and there is nothing to irritate 
it. In all but the slightest cases, however, there 
is a constant sense of fulness and tenesmus; nor- 
mal motions are never passed; the amount of dis- 
charge increases; it loses its simple mucous charac- 
ter, and becomes dark, like coffee-grounds. Con- 
trol over the sphincter is lost; the skin around the 
anus is constantly moist; it becomes covered with 
vegetations and excrescences, between which 
fissures form. Then the pain becomes more severe; 
after each motion it is intense, and in the intervals 
there is always a constant dull aching. Finally, 
the diarrhea becomes almost continuous; health 
and strength fail; the appetite is lost; colicky 
spasms and pains over the lower part of the abdo- 
men grow more frequent; abscesses and fistulae 
form around the bowel; the emaciation becomes 
extreme; and the patient sinks from exhaustion, 
if he is not carried off by some intercurrent dis- 
order. 
Diagnosis.-In advanced cases the appearance 
of the anus at once suggests the presence of more 
serious mischief. The thickened and pigmented 
folds, with deep and painful ulcers in between, and 
the eczematous condition of the skin, can only 
be caused by long-continued irritation; but the 
diagnosis can be made only with the finger or the 
speculum. The former is usually sufficient; the 
latter can only be used with an anesthetic, and 
with either the utmost gentleness is essential. 
Immediately inside the anus the mucous mem- 
brane is generally unaffected, though both in 
syphilis and advanced tubercular or lupoid disease 
it may be nearly as bad as the rest; higher up, the 
normal soft character of the bowel is entirely 
lost. The surface is rough and irregular; hard 
nodules project here and there; in some places the 
walls are dense and thick, like stricture tissue, and 
the passage is narrowed; in others there are soft 
smooth patches, surrounded with overhanging 
edges, which bleed at the least touch; and the fin- 
ger, when it is withdrawn, is smeared with blood- 
stained mucus. Sometimes it is possible from 
this alone to form an opinion both as to the extent 
and cause of the disease. Syphilitic ulceration is 
often accompanied by other signs; tubercle rarely 
leads to the formation of dense cicatrices, and 
fistulae generally make their appearance very soon. 
Dysentery, on the other hand, may destroy all 
trace of normal mucous membrane, and often 
extends far beyond the reach of the finger. In the 
majority, however, a careful inquiry into the his- 
tory and into the other symptoms that are present 
is essential; and even then it is sometimes difficult 
to exclude the idea of malignant disease. 
Treatment.-Rest is the first consideration. The 
patient must lie down for at least the greater part 
of the day, with the foot of the bed raised to pre- 
vent venous congestion. The feces must be kept 
as soft and as small as possible; everything that is 
stimulating or indigestible, or likely to leave a 
bulky residue, must be strictly avoided. Pure 
milk diet for a time is often advantageous. All 
straining must be prevented; the bowel must be 
washed out night and morning with warm water or 
an astringent lotion-nitrate of silver in the case 
of dysentery, lotio nigra for syphilis; and after this 
a simple unirritating ointment (calomel-10 
grains to about 1 ounce-subnitrate of bismuth, 
iodoform, or nitrate of mercury) may be applied, 
either as a suppository or with a suitable oint- 
ment introducer. Starch and opium injections 
are excellent means of controlling the diarrhea. 
In the meanwhile constitutional treatment 
must not be neglected. Potassium iodid must 
be given in syphilitic cases. Cod-fiver oil, if the 
patient can take it, often answers better than 
anything, as there is nearly always great loss of 
flesh and strength, and it tends to keep the motions 
soft; if iron is given, care must be taken that the 
bowels are not confined. In a few cases, when the RECTUM, INFLAMMATION 
RECTUM, INFLAMMATION 
ulcer is low down and the spasmodic contraction 
of the sphincter is severe, perfect rest may be 
obtained by subcutaneous division of the muscle 
or by stretching it; but this is seldom beneficial 
in the more severe forms. In these, when all 
local treatment fails, colotomy is the only resource 
(Moullin). 
Periproctitis.-Inflammation around the rectum 
may occur at the anus, in the ischiorectal fossa, 
or higher up in connection with the insertion of 
the levator ani and the rectovesical fascia. 
Inflammation around the margin of the anus in 
many cases is symptomatic of some deeper infec- 
tion. There is a constant offensive discharge 
from the anus, the parts are continually moist, 
the epidermis is macerated, and the deeper papil- 
lary layer of the skin is exposed. Inflamed external 
hemorrhoids, small cutaneous boils, suppuration 
in connection with the hair follicles, and syphilitic 
eruptions are not uncommon. Of itself, it may 
be trivial in character, but it becomes of great 
importance from the tendency it has to leave be- 
hind it painful fissures and superficial fistuke. 
Ischiorectal abscess is more serious. It may be 
acute or chronic. In the former case the symp- 
toms closely resemble those of proctitis. It may 
commence with a rigor; the pulse is quick, the 
tongue furred; there is the most intense throbbing 
in the perineum; sitting down is almost impossible; 
the rectum feels as if it was loaded with feces, but 
the least attempt at relief brings on the most 
violent pain and straining. On examination there 
is a hard brawny swelling by the side of the anus; 
the skin is red and edematous, pitting on pressure; 
and if the finger is introduced into the bowel, the 
hardness can be felt through the wall for some dis- 
tance above. Sometimes the inflammation is even 
more acute than this, and a form of gangrenous 
cellulitis, which may prove fatal, sets in. In the 
chronic form, on the other hand, the swelling is 
painless, and often lasts for weeks. There is 
merely a soft, fluctuating swelling, filling the whole 
of the ischiorectal fossa and extending up by the 
side of the bowel, covered by a thin layer of dis- 
colored skin. Not infrequently the patient is 
almost unaware of its existence, and it may attain 
a very large size and burrow for a considerable 
distance before the skin gives way. When this 
happens, the opening is always large and ragged, 
with thin overhanging edges, like those of a 
scrofulous sore, and a fistula is almost certain to 
be left. The frequency with which these abscesses 
occur is accounted for by the ease with which septic 
absorption takes place through abrasions of the 
mucous surface, partly owing to the anatomy of 
the region. Owing to the rapid variations in size 
of the bowel, the tissues are badly supported; the 
circulation is feeble; there is a large amount of loose 
fat, with dilated veins; and the vessels have even a 
grearer tendency to become varicose than those 
of the lower extremities. 
Phlegmonous inflammation is rare, except in 
patients who are thoroughly broken down; most 
of the cases recorded have been in persons who were 
suffering from specific fevers. Acute abscess may 
usually be traced to injury; perforation of the 
mucous membrane from the inside by a fish- 
bone or other foreign body; tearing of the mucous 
surface from straining or the passage of hardened 
feces; or bruising of the subcutaneous tissue, 
leading to extravasation in the ischiorectal fossa 
or to venous thrombosis. The chronic form is 
probably due in a very large number of cases to 
the breaking down of tubercular deposit in con- 
nection with the adenoid tissue of the rectum; 
or it may be a complication of stricture, beginning 
either from an ulcer on the mucous surface or, in- 
dependently of this, in the inflammatory exudation 
surrounding the bowel. In addition to this, sup- 
puration may extend into the ischiorectal fossa 
from distant organs. Urinary abscess is not 
uncommon; necrosis of the sacrum or coccyx 
occasionally gives rise to it; coccygeal dermoid 
cysts may cause it; and it has been known in caries 
of the lumbar vertebrae. 
Treatment.-Ischiorectal abscesses should be 
opened at once, and freely, or a fistula is almost 
certain to form. Even if there is merely a tense, 
hard, and painful swelling, it is better to run the 
risk of not finding pus. If the abscess is small and 
close to the rectum, so as to give rise to the sus- 
picion that it is really intramural, the patient 
should be placed upon his side, with the knees 
drawn up, and the finger introduced into the bowel 
to fix the swelling and make it project toward the 
skin. Then a straight bistoury is introduced, 
and an incision, sufficiently free to give exit to the 
pus, made radially from the anus. Some of the 
outer fibers of the external sphincter are divided, 
to prevent the opening from closing too soon. 
True ischiorectal abscesses, on the other hand, 
must be laid freely open by a longitudinal incision, 
parallel to the anus, midway between it and the 
ischium; and as soon as the pus has escaped, the 
finger must be introduced, the cavity explored, and 
the partitions inside broken down. Afterward, the 
opening must be kept patent to insure the abscess 
healing from the bottom. Lint should be avoided, 
as the discharge is liable to collect behind it, and 
its removal is very painful. Guttapercha tissue, 
folded irregularly so as to fit inside the orifice 
without blocking it, is the most convenient. The 
cavity, if the dressing does not come away easily, 
can be syringed out behind it, and it does not 
absorb the discharge. The patient should be kept 
in bed, or at least lying down, until the abscess 
has healed. If it is an acute one this will not be 
many days; if it is chronic, the greatest care is 
necessary to prevent it degenerating into a fistula. 
The bowels should be well opened once, and then 
kept confined for several days, the diet being very 
light, so that there may not be an accumulation of 
feces. When they are opened, an effectual 
purge should be given to avoid straining. 
Inflammation on the Visceral Surface of the 
Levator Ani.-This is nearly always caused by 
extension from some of the neighboring viscera, 
and if it involves the rectum, is nearly always 
associated with stricture. Occasionally it origi- 
nates from the bowel; much more frequently 
from the uterus, following parturition or metritis, 
and probably it is for this reason that stricture of RECTUM, INJURIES 
RECTUM, PROLAPSE 
the rectum is so much more common in women 
than in men. The inflammation may be acute, 
attended with high fever, and soon ending in sup- 
puration; or chronic, spreading from one part to 
another until they are firmly bound down to each 
other and to the pelvis by bands of cicatricial tissue, 
which may be almost of cartilaginous hardness. 
When it starts from the region of the uterus, the 
anterior surface of the rectum is first involved. 
The inflammatory exudation spreads into the sub- 
stance of the muscles until the fibers become atro- 
phied and the walls hard and unyielding; the 
mucous membrane becomes rigid and unable to 
unfold itself; the constant irritation caused by the 
passage of the feces gradually leads to hyperemia 
and thickening of the submucous tissue; and, 
at length, a definite stricture is formed, which may 
either be tubular in shape, extending for some 
distance along the bowel, especially on the anterior 
surface, or sharp, well-defined, and annular, about 
1 1/2 or 2 inches above the anus. If suppuration 
occurs, the abscesses may break into the bladder 
or vagina, or they may extend through thesac- 
rosciatic foramina, or even burst into the peri- 
toneal cavity (Moullin). 
RECTUM, INJURIES.-Injuries of the rectum 
occasionally occur from falls upon sharp-pointed 
bodies, or from incautious attempts to pass a long 
enema tube or bougie. Should the peritoneal 
cavity be perforated, death is the almost invariable 
consequence, especially if any injection has been 
absorbed by the peritoneum before the mistake is 
discovered. 
Treatment.-Opening the abdomen, flushing 
out the peritoneum, and sewing up the rent in the 
gut affords the only hope of cure. 
Foreign Bodies in the Rectum.-Foreign bodies o 
many differing kinds have at times been accident 
ally or intentionally introduced into the rectum. 
Fish-bones that have been swallowed not infre- 
quently become impacted just within the anus, 
there giving rise to much irritation or pain, and 
often causing an ischiorectal abscess. The re- 
moval of some of these bodies, when of large size, 
is frequently attended with considerable difficulty, 
requiring an anesthetic, dilatation of the sphincter, 
and the use of various forceps, or even the passage 
of the whole hand. 
RECTUM, PROLAPSE.-Prolapsus recti is the 
protrusion of the mucous membrane of the lower 
part of the rectum, and, more rarely, of the muscu- 
lar coat as well, through the anus. It is most com- 
mon in children, but may occur at any age. 
The causes are either a relaxed state of the 
sphincter, induced by general weakness; residence 
in hot climates, etc.; or excessive straining due 
to stricture of the urethra, phimosis, stone, as- 
carides, constipation, piles, or polypus. 
Symptoms and Diagnosis.-It commonly appears 
as an irregular ring of mucous membrane, or when 
much is protruded as a cylindric, elongated swel- 
ling. When recent, it has the color of healthy 
mucous membrane; but if not soon reduced it may 
become livid and congested, in consequence of 
constriction of the blood-vessels by the sphincter. 
The strangulation may proceed to such an extent 
that the prolapsed portion may undergo mortifica- 
tion and slough away. In old-standing cases it 
becomes indurated and leathery from exposure. 
It may be diagnosed from polypus by the presence 
of a central aperture, and from intussusception by 
the mucous membrane being continuous with that 
of the sphincter. In intussusception a sulcus 
exists between the protruded part of the bowel 
and the sphincter. 
Treatment.-Should the bowel be protruded or 
strangulated, an attempt should be made to re- 
duce it. If it has only been prolapsed a short 
time, this is easily accomplished by gentle pres- 
sure, the parts having been well smeared with 
vaselin, and the buttocks raised. When of longer 
standing, firm pressure must be exercised on it for 
10 minutes or so, or the finger may be introduced 
into the orifice and the bowel pressed back. If 
reduction fails and the part is much inflamed, an 
ice-bag may be applied, and another attempt sub- 
sequently made, when, if still unsuccessful, nothing 
remains but to allow the protruded part to slough 
off or to excise it. If the muscular coat protrudes, 
no operation should be done, lest the peritoneum be 
wounded. Having reduced the bowel, the cause 
of the prolapse should, if possible, be removed; and 
to prevent a recurrence, the nates may be strapped 
together, or a pad and T-bandage worn, and the 
motions passed at bedtime instead of in the 
morning, the patient lying on his side or back dur- 
ing defecation. Astringent lotions or ointments of 
sulphate of iron, galls, or tannin should be applied, 
or the mucous membrane painted with nitrate of 
silver, while any pendulous folds of skin may be 
snipped off, so as to cause some amount of con- 
traction of the anus. In the meanwhile the mo- 
tions should be rendered soft with gentle laxatives. 
Should these means, after being well persevered in, 
fail, a more serious operation may become neces- 
sary. Comparatively recently the main active 
treatment of rectal prolapse consisted in chemical 
or thermal destruction of protruding mucous 
membrane or of portions of the dilated anus, the 
scar contraction incident to healing leading to 
narrowing of the anus and support of the gut. 
Strangulation of the protruding tissues by means 
of ligatures was also recommended and often gave 
good results. All such measures ought to be dis- 
carded, as chemical and thermal action are diffi- 
cult to regulate and the strangulation by ligature is 
distinctly dangerous. There are three distinct 
principles, each of which is the base of a modern 
method of operative treatment. 
1. When the prolapse is due to sphincteric 
atony or looseness, the principle of treatment is to 
overcome this condition by narrowing the sphinc- 
ter. 
2. When the prolapse is due to want of superior 
support, such support must be provided. 
3. When there is excess of rectum and much 
tissue is prolapsed, the protruded mass should be 
excised. Generally this excision must be supple- 
mented by narrowing the sphincter. 
Thus according to the indications in the individ- 
ual case plastic operations may be performed 
upon the sphincter ani, the lumen of the rectum RECTUM, STRICTURE 
RECTUM, STRICTURE 
narrowed, the rectum or sigmoid raised to a higher 
level and retained by sutures. The operation of 
sigmoidopexy, in which the peritoneal cavity is 
opened and the sigmoid flexure sutured to the 
abdominal walls is advocated by a number of 
surgeons. Excision of the prolapsed bowel is 
not advised. 
RECTUM, STRICTURE.-Stricture of the rec- 
tum may be divided into the simple and the 
malignant. 
The simple or fibrous stricture may be caused by 
the fibroid contraction of inflammatory products in 
the mucous and submucous coats, or of cicatrices 
following simple, syphilitic, or dysenteric ulcera- 
tion; by injury, or operation on the bowel; or it 
may be the result of pelvic inflammations. 
Pathology.-The stricture is generally situated 
from 1 to 2 inches from the anus, but may occur 
at any part. It may involve only a narrow, ring- 
like portion, when it is called annular; or it may in- 
clude an inch or more of the gut, when it is some- 
times spoken of as tubular. The strictured portion 
of the bowel consists in great part of fibrous tissue. 
The syphilitic variety is often combined with con- 
dylomata or ulceration about the anus, and the 
mucous membrane between the anus and the stric- 
ture is frequently ulcerated. The bowel above is 
generally distended with feces, the muscular coat 
hypertrophied, and the mucous membrane ulcer- 
ated ; while in the neighborhood of the stricture the 
coats are often so thin that the least force causes 
them to give way. Fistute often form below the 
stricture, and hemorrhoids are a frequent con- 
comitant. 
Symptoms and Diagnosis.-Pain and difficulty in 
passing a motion, constipation, and, later, consti- 
pation alternating with diarrhea. The motions, 
when the stricture is near the anus, become small, 
ribbon-like, and streaked with discharge. There 
is a frequent desire to defecate, but little passes ex- 
cept gas and mucus, or pus, and the bowel feels as if 
it had not been emptied. In tight strictures or in 
strictures with ulceration Astute may sometimes 
form about the anus, and the patient gets worn out; 
and after many years, perhaps, of suffering may 
die of an attack of peritonitis or obstruction. The 
stricture is readily detected on passing the finger, 
but is often so tight that only the tip can be in- 
serted. When this is the case, on no account 
should the finger be passed through it, as the 
slight force of passing the finger may rupture the 
attenuated walls, and peritonitis and death may 
follow. 
Treatment.-As a rule, gradual dilatation by 
means of bougies should be first attempted, and 
will generally be successful; but the stricture must 
be kept dilated by the subsequent occasional pas- 
sage of a bougie. In exceptional cases, when the 
stricture is very resistant, a bougie may be tied in. 
When the parts are much riddled by fistute, a 
division of the stricture may be necessary. This 
may be done by what is called internal or external 
linear proctotomy. In the former operation the 
knife, guided by the finger, is introduced through 
the stricture, which is then divided in a posterior 
direction; in the latter, the stricture, together with 
the external sphincter and other intervening soft 
parts, are completely divided down to the coccyx. 
Malignant or Cancerous Stricture.-Cancer in 
all its forms may occur in the rectum, but the most 
common is a variety of carcinoma known as the 
columnar or adenoid. It occurs either as a 
fungating, more or less distinct tumor projecting 
into the lumen of the bowel; or as a laminar, nodu- 
lar, or ring-like infiltration of its coats. In either 
case it is at first covered by apparently unaltered 
mucous membrane, which, however, is sooner or 
later destroyed by ulceration, leaving an ulcer with 
an uneven, proliferating, or excavated surface, 
everted edges, and an indurated base. As the dis- 
ease extends, it involves the muscular coat, and 
subsequently the surrounding structures and 
organs, gluing them, as it were, to the rectum, and 
finally converting the whole into a cancerous mass. 
The lymphatic glands in the pelvis, and later the 
inguinal glands and others more removed, become 
affected, and the carcinoma may finally be dis- 
seminated, secondary growths being more espe- 
cially met with in the liver. 
The symptoms are often very insidious. At 
first there may be merely some uneasiness, hardly 
amounting to pain, about the anus; then more or 
less pain on defecation is noticed; the feces may 
be streaked with mucus or with blood, and a 
slimy discharge may be present. Later, the mo- 
tions become small, flattened, or pipe-like when 
the stricture is near the anus, or scybalous when 
some distance above. The patient strains at 
stool, and feels as if his bowel had not been emp- 
tied; then there is constipation, alternating with 
diarrhea, and an offensive sanious discharge. 
Emaciation and cachexia now come on, with more 
local pain, and the patient dies of exhaustion, peri- 
tonitis, or during an attack of acute obstruction. 
The diagnosis can only be arrived at by a local 
examination. The anus generally appears healthy, 
though probably patulous, and a healthy strip of 
mucous membrane generally exists between the 
anus and the growth. When the growth can be 
felt, its indurated base, and when ulceration has 
occurred, the everted edges of the ulcer, and the 
sanious and foul discharge, render the diagnosis 
generally easy. When beyond the reach of the 
finger, it may at times be brought down by the 
patient straining. The fungating form may be 
mistaken for a villous growth; the annular, for a 
simple fibrous stricture. A villous growth may be 
distinguished by its velvety and supple feel, by the 
fact that it does not ulcerate nor break down, by 
the absence of induration, by the thin and mucoid 
discharge, by the brightness and scarcity of the 
blood, by the unattached rectum, and by the 
duration of the disease. A fibrous stricture may be 
known by its longer duration, by being less indu- 
rated than the cancerous form, by the bowel not 
being fixed, and, when due to syphilis, by the 
absence of a healthy strip of mucous membrane 
between the growth and the anus. 
Treatment.-If the disease is seen sufficiently 
early, and before it has involved the surrounding 
parts, if it is not situated too high up in the rectum, 
and if the general condition of the patient is other- RECTUM, TUMORS 
RECTUM, TUMORS 
wise favorable, excision of the growth with the 
lower end of the rectum should be undertaken, as 
in this way the whole may be removed, and not 
without reasonable hope, in some of the less malig- 
nant forms of the disease, of its not returning. 
Some cases have been reported in which it has not 
done so for upward of 4 years. Previous to 
removal of the rectum it may be wise to perform 
inguinal colotomy, since after this operation there 
is less risk of the wound left by the excision becom- 
ing septic. When removal seems impracticable, 
or otherwise inadvisable, such palliative measures 
should be adopted as may render the last few 
months or years of the patient's fife as comfortable 
as possible. Thus, the bowels should be kept 
gently relaxed, the diet regulated, and the pain 
relieved by morphin suppositories. In this way 
the patient can often follow his occupation in com- 
parative comfort and with little inconvenience. 
Should, however, there be very frequent calls to 
defecate, much pain and irritation on the passage 
of feces, or obstruction threaten or have already 
occurred, colotomy should be performed. This 
operation should not, as is too frequently the 
case, be regarded merely as a last resource, to be 
undertaken when obstruction has come on, as then 
the danger of the operation is greatly increased. 
Nor should it be undertaken in every instance, 
since the inconvenience caused by the cancer is 
not always sufficient to justify the patient under- 
going the risk (Walsham). 
Excision of the rectum may be performed if the 
finger can be passed beyond the growth, if the 
growth is movable, if the glands are not involved, 
and if the patient is otherwise fairly healthy. The 
patient having been placed in the lithotomy posi- 
tion, and a staff introduced into the bladder, a 
curved bistoury should be passed along the finger 
up the rectum, and its point made to emerge near 
the coccyx, and the intervening tissues cut through 
in the middle line. By this incision a free expo- 
sure is obtained. Lateral incisions are next made 
on each side of the anus, meeting in front, and the 
bowel is rapidly cleared, either with the finger or 
with the handle of the scalpel, from the tissues of 
the ischiorectal fossa. The lower part of the 
rectum is now dissected more carefully from the 
urethra and prostate, and when it has been suffi- 
ciently freed, the ecraseur is placed above the 
growth, and the rectum removed, care being taken 
that the cord when tightened is not pulled down 
below the spot where it is intended to sever the 
bowel. If preferred, the scissors may be substi- 
tuted for the ecraseur, the vessels being then tied as 
they are cut. When the growth does not involve 
the whole of the bowel, a strip of mucous mem- 
brane should, if possible, be left. The wound 
should be plugged for 24 hours with iodoform 
gauze if there is much oozing, and the parts sub- 
sequently irrigated frequently. More of the rec- 
tum may be removed by resection of the coccyx 
and lower part of the sacrum, the incision extend- 
ing backward and to the left side (Kraske's opera- 
tion). 
RECTUM, TUMORS. Polypi.-The term poly- 
pus has been erroneously applied to almost any 
outgrowth from the mucous membrane that pro- 
jects into the cavity of the bowel. A polypus 
should be pedunculated, but it may be sessile, pro- 
vided the base is relatively small; and it may be a 
new growth altogether-adenoma or fibroma-or a 
mere overgrowth of the normal tissue of the part. 
Generally, polypi are single, growing within a 
short distance of the anus, from the dorsal sur- 
face of the bowel; but sometimes there are 2 or 3, 
and in a few instances there have been hundreds. 
As a rule, their size is not large; the fibrous ones 
are seldom larger than a walnut, and adenomta 
in most instances are not so large; but when there 
are 2 or 3 together, they have been known to block 
up the interior, and give rise to symptoms of 
obstruction. The soft polypus is most frequent 
in children. It is generally the size of a raspberry, 
bright red in color, smooth or slightly granular 
on the surface, and bleeds at the least touch. It 
is composed mainly of tubules lined with columnar 
epithelium, like Lieberkuhn's follicles, held to- 
gether by a delicate connective tissue, and dilated 
in places into cysts; sometimes there is a little more 
fibrous tissue, and occasionally a few unstriped 
muscular fibers. At first they are sessile, but as 
they rarely give rise to symptoms until they pro- 
trude from the anus, a long and slender pedicle is 
generally present by the time the diagnosis is made. 
Fibrous polypi, on the other hand, are rare except 
in adults. They spring apparently from the sub- 
mucous layer, and are composed of fibrous tissue, 
which may be so hard as to creak when divided 
with a knife. It has been suggested that they are 
really adenoid polypi, which in course of time have 
become hardened and condensed by constant irri- 
tation. Occasionally, it is almost impossible to 
distinguish them from internal hemorrhoids. 
Beside these, polypoid outgrowths of mucous 
membrane, hypertrophied from persistent irrita- 
tion, are often present in cases of fissure just inside 
the anus. 
Symptoms.-These are not definite until the 
pedicle is long enough to be grasped by the bowel. 
In children, bleeding from the anus is often the 
first thing noticed, and in the absence of injury 
may be regarded as almost conclusive. Sometimes 
the growth is extruded during defecation, and is 
caught by the sphincter, giving rise to pain and 
spasm; and it may even slough off, and undergo 
spontaneous cure. In adults hemorrhage is not so 
conspicuous, but there is usually a considerable 
discharge of mucus, like thin starch or white of 
egg, not only with the motions but in the intervals. 
If the polypus comes down, the pain and irritation 
may be very severe, and it may drag the bowel 
down with it so as to cause prolapse, or, if it is 
situated higher up, intussusception. 
A protruding polypus can be recognized at once 
by its appearance. If it is not visible at first, an 
injection may be given, and the part examined 
immediately after. When the finger is introduced, 
it is advisable to pass it up to its full length at once, 
and search the mucous membrane as it is with- 
drawn; otherwise a polypus with a slender pedicle 
may be pushed up in front of it and missed. 
Treatment.-Polypi may be removed by torsion RECTUM, TUMORS 
REFLEXES 
and ligation. The former answers very well in 
children, and if the pedicle is really twisted off, is 
not followed by hemorrhage; the latter is better if 
the pedicle is of any size, or if the growth is 
fibrous. An anesthetic is advisable. If a liga- 
ture is used, precautions should be taken to avoid 
ulceration. 
Villous growths, similar to, but rather coarser 
than, the fimbriated papilloma of the bladder, are 
occasionally met with in the rectum. Allingham, 
who has had the widest experience with this con- 
dition, describes these growths as forming soft, 
lobulated, spongy masses, either sessile or with a 
pedicle formed from the subjacent mucous mem- 
brane. In most cases they grow from the posterior 
wall rather high up, and by far the greater number 
occur in people over 50 years of age. In some 
they cause severe hemorrhage, and the growth 
occasionally becomes prolapsed; but the most 
striking feature is the constant discharge of large 
quantities of thin watery mucus. The diagnosis, 
unless some portion of the growth is forced out 
through the anus, is exceedingly difficult, owing to 
the peculiarly soft, velvety feel of the mass, which 
prevents distinguishing it from the natural folds 
of the mucous membrane. The only treatment 
is free excision; and this is especially necessary, as 
in a large proportion of cases malignant disease 
follows (Moullin). 
Nevus of the rectum is occasionally met with, 
and may give rise to very profuse hemorrhage. 
Hemorrhoids.-See Hemorrhoids. 
REFLEXES.-Reflex movement is caused by 
the stimulus of an afferent nerve, and the trans- 
ference or return, by a center, of the impulse 
through an efferent nerve, resulting in movement 
or function of a peripheral organ. Reflexes may 
be motor, sensory, secretory, tactile, or inhibitory. 
See Nervous Diseases (Examination). A table 
of reflexes is herewith appended. 
REFLEXES, TABLE OF. 
Name. 
Deep or 
Superficial. 
How Obtained. 
Effect Produced. 
Significance. 
Abdominal 
Superficial 
Sharp, sudden stroking of 
abdominal wall from 
margin of ribs down- 
ward. 
Contraction of muscles 
about umbilicus. 
Shows integrity of cord 
from eighth to twelfth 
dorsal nerve. 
Ankle-clonus 
Deep 
By sudden complete flex- 
ion of foot, by pressing 
hand against sole. 
Clonic contractions of 
tendo Achillis, depend- 
ent upon alternate con- 
traction and relaxation 
of anterior tibial and 
calf muscles. 
As in knee-jerk. 
Argyll Robertson... 
See Robertson, Argyll. 
• 
Babinski 
Deep 
Irritation of the skin of 
the sole of the foot. 
Extension instead of flex- 
ion of the toes. 
Lesion of pyramidal tract. 
Found in organic, but 
not hysteric, hemiplegia. 
Biceps 
Deep 
Tapping tendon of biceps. 
Contraction of biceps mus- 
cle. 
Same cases as increased 
knee-jerk. 
Ciliospinal 
Superficial 
By irritation of the skin of 
the neck. 
Pupillary dilatation. 
Conjunctival (cor- 
neal). 
Superficial 
Irritation of conjunctiva.. 
Contraction of orbicularis 
palpebrarum. 
Abolished by complete 
anesthesia, deep stupor 
coma. 
Cremasteric 
Superficial 
Stimulation of skin on 
front and inner aspect 
of thigh. 
Retraction of testicle on 
same side. 
Shows integrity of cord be- 
tween the first and second 
lumbar pairs of nerves. 
Crossed 
Deep 
Stimulation of one side of 
body. 
Reflex on opposite side of 
body. 
Deep 
Reflexes developed by per 
cussion of tendons or bones. 
Dorsal 
Superficial 
Same as Erector spince. 
Elbow-jerk. 
Epigastric 
Superficial 
Stimulation of skin in fifth 
or sixth intercostal space 
near axilla. 
Dimpling in the epigas- 
trium, due to contrac- 
tion of the highest fibers 
of the rectus abdominis 
muscle. 
Shows integrity of cord 
from fourth to seventh 
dorsal nerves. 
Erector spin® 
। Superficial 
Stimulation of skin along 
| border of erector spinse 
muscle. 
Local contraction of these 
muscles. 
Integrity of dorsal region 
of cord. REFLEXES 
REFLEXES, TABLE OF. 
REFLEXES 
Name. 
Deep or 
Superficial. 
How Obtained. 
Effect Produced. 
Significance. 
Front-tap 
See Tendo Achillis. 
Gluteal 
Superficial 
Firm sudden stroking of 
skin over buttock. 
Contraction of glutei 
Shows integrity of cord at 
fourth and fifth lumbar 
nerves. 
Interscapular 
Superficial 
See Scapular. 
Iris-contraction.... 
Superficial 
See Pupillary. 
Jaw-jerk, or jaw- 
clonus. 
Superficial 
Downward stroke with a 
hammer on the lower 
jaw hanging passively 
or gently supported by 
the hand. 
Clonic movements of infe- 
rior maxilla. 
Rarely present in health. 
Knee-jerk 
Deep 
By striking patellar ten- 
don after rendering it 
tense by flexing the knee 
at right angle. 
Contraction of quadriceps 
muscle, foot jerked for- 
ward. 
Normal in health. Absent 
in locomotor ataxia, de- 
structive lesions of lower 
part of cord, alcoholic 
paraplegia, affections of 
the anterior gray cornua, 
infantile paralysis, me- 
ningitis, diphtheritic 
paralysis, atrophic palsy, 
pseudoh y per trophic 
muscular paralysis, 
diabetes, etc. Increased in 
diseases of the pyram- 
idal tracts, in spinal irri- 
tability, tumors of brain, 
cerebrospinal sclerosis, 
lateral sclerosis, after epi- 
leptic seizures or uni- 
lateral convulsions. 
Laryngeal 
Superficial 
Irritation of fauces, larynx, 
etc. 
Cough 
Lumbar 
Superficial 
Same as Erector spince.... 
Nasal 
Superficial 
Irritation of Schneiderian 
membrane. 
Sneezing 
Obliquus 
Superficial 
Irritation of skin below 
Poupart's ligament. 
Contraction of fibers of 
external oblique in fe- 
males; corresponds to 
cremasteric in males, 
although it can also be 
caused in males. 
Ophthalmic (sup- 
raorbital). 
Superficial 
Blow struck over supra- 
orbital nerve. 
Slight contraction of or- 
bicularis palpebrarum 
muscle. 
Palatal 
Superficial 
Irritation 
Swallowing. 
Palmar 
Superficial 
Tickling of palm 
Contraction of digital 
flexors. 
Shows that cervical region 
of cord is normal. 
Patellar 
Deep 
Same as Knee-jerk. 
Patellar, Paradoxic 
Superficial 
Percussing patellar tendon 
with the patient in the 
dorsal decubitus. 
Contraction of the adduc- 
tor, but not of the quad- 
riceps muscle. If the 
patient be in the sitting 
posture the normal re- 
flex is elicited 
Spinal concussion. 
Penis-percussion.. . 
Superficial 
See Virile. 
Periosteal 
Deep 
Tapping the bones of the 
forearm or leg. 
Sharp contractions of the 
muscles. 
Indicates disease of the 
spinal cord (amyotrophic 
lateral sclerosis). 
Peroneal 
Superficial 
Stroke on peroneal mus- 
cles when tense or when 
the foot is turned in- 
ward 
Reflex movements. 
* REFRACTION OF THE EYE 
REFRACTION OF THE EYE 
Name. 
Deep or 
Superficial. 
How Obtained. 
Effect Produced. 
Significance. 
Pharyngeal 
Plantar 
Superficial 
Irritation 
Swallowing. 
Superficial 
Stroking sole of foot 
Contraction of toes 
Muscular exertion. 
Platysma 
Superficial 
Pinching the platysma 
myoides muscle. 
Dilatation of pupil. 
Pupillary 
Exposure of retina to 
light. 
Contraction of iris 
Absent in basal meningitis, 
etc. 
Paradoxic Pupil- 
lary. 
Stimulation of retina by 
light. 
Dilatation of pupil 
In rare abnormal states. 
Paradoxic Patellar. 
See Patellar, Parad 
oxic. 
Reinforced 
Any reflex is heightened by coincident muscu 
mental distraction. 
ar exertion of other parts than those being tested or by 
Robertson, Argyll. 
Light and accommoda- 
tion. 
Pupil reacts in accommo- 
dation, but not to light. 
Locomotor ataxia. 
Scapular 
Superficial 
Irritation of interscapular 
region. 
Contraction of scapular 
muscles. 
Shows integrity of cord be- 
tween upper two or three 
dorsal and lower two or 
three cervical nerves. 
Skin 
Superficial 
See Platysma. 
Sole 
Same as Plantar. 
Spinal 
Those reflex actions emanating from centers in the spinal cord. 
Superficial 
Such as are developed from irritation of the skin. 
Tendo Achillis, or 
front tap contrac- 
tion. 
Superficial 
By striking muscles on 
anterior part of leg, 
while in extension, the 
foot being extended by 
the hand upon the sole. 
Reflex contraction of gas- 
trocnemius. 
Considered by Gowers as 
a delicate test of height- 
ened spinal irritability. 
Toe (great) 
- - . - 
Superficial 
Strong flexion of great toe. 
Involuntary flexion of foot, 
then flexion of leg. and, 
lastly, flexion of the 
thigh on the pelvis. 
Met with in cases in which 
the knee-jerk and other 
t e n d o n-r e fl e x e s are 
strongly developed. 
Virile 
Superficial 
Sharp percussion of back 
of penis, the sheath 
having been made tense. 
Retraction of bulbocaver- 
nous portion. 
Occurs in health. 
Wrist-clonus 
Deep 
By pressing hand back- 
ward, causing extreme 
extension. 
A series of jerking move- 
ments of the hand. 
In the late rigidity of 
hemiplegia. 
REFLEXES, TABLE OF. 
REFRACTION OF THE EYE.-The case of 
test-lenses should contain a set of + spheric lenses 
and - spheric lenses in pairs from 0.12 D. to 20 D.; 
a set of + cylinders and - cylinders from 0.12 to 
at least 6 D., and a set of prisms from 0.5 degree 
to at least 20 degrees; several plain-colored glasses, 
opaque glasses, blanks, stenopaic discs, etc., and a 
trial-frame. 
Trial-frames for test-lenses are of several varie- 
ties. The most common form consists of an ar- 
rangement whereby the nose-piece may be rapidly 
adjusted by means of a screw, so as to make the 
frame conform to any height or depth of the bridge 
of the patient's nose. A vertical and horizontal 
adjustment by a rack-and-pinion movement on the 
nose-piece enables us to quickly and perfectly 
adjust the frame to any peculiarity of the patient's 
face. A millimetric scale with a pointer moved by 
a double rack-and-pinion device gives the distance 
between the pupils at a glance. The lens-holder 
consists of two hollow grooves, with a slot in each 
eye-piece to permit rotation of cylindric lenses 
with handles. On the outside of each eye-piece 
are hooks for adjusting an additional lens or a 
blinder. The markings on the eye-pieces begin at 
zero at the nasal side, and run to the temporal side 
to 180 degrees. The axis at which the cylinder is 
inclined is found by comparing the axis marked 
on the test-cylinder with the coinciding number 
on the trial-frame. However, as the trial-frame 
is not often perfectly adjusted, it is well for the 
surgeon to learn to estimate the angle, particularly 
in the vertical and horizontal meridians, with his 
eye. In placing strong lenses in the trial-frame it 
is well to have the convex surface of convex lenses 
turned away from the eye, and the concave surfaces REFRACTION OF THE EYE 
RELAPSING FEVER 
of concave lenses turned toward the eye. In all 
cases the lenses should be placed as near the eye as 
possible. 
Practical Procedure with the Test-lenses.- 
Having been assured that all the accommodation is 
suspended, seat the patient to the left of the table 
containing the test-lenses, and commence the 
examination with the right eye, covering the left 
with an opaque lens or metal disc. Then ask the 
patient to read down the card situated at 5 or 6 
meters' distance, until he comes to the letters that 
are indistinct; then commence the application of 
the lenses. Experience will give a good idea what 
lens to start with, by noting the amount of inter- 
ference with vision after mydriasis. If the patient 
is able to recognize only the largest letters on the 
card, he is either amblyopic, myopic, or highly 
hyperopic, and is quite likely in every case astig- 
matic. If the patient is amblyopic from intra- 
ocular disease or other cause, the application of a 
pin-hole perforated disc will not increase his vision, 
and it is not likely that glasses will improve his 
sight. If the trouble is only refractive, he will at 
once notice an improvement in vision through the 
small perforation. If he is astigmatic, he will 
select the stenopaic disc (a blank disc with a small 
open slit, described under Astigmatism (q. v.)) at 
an angle corresponding to the axis of his astigma- 
tism, and the two meridians may be refracted 
separately by spheric lenses alone. 
It is perhaps well to assume the simplest exami- 
nation of a moderate degree of ametropia. First 
using a low power + spheric lens (0.25), inquire 
if the confused letters are improved by it; if the 
patient answers, yes, try a corresponding strength 
astigmatic lens starting at axis 90 degrees, and 
inquire if the vision is still better; then rotate the 
cylinder in the frame, finding the axis at which the 
letters are seen best. If the patient prefers 
the cylinder to the spheric lens, put on the cylinder 
at the axis preferred, and determine the line read 
with this correction. A low power + spheric lens 
(0.25) is held in1 front of the eye that is already 
corrected by a cylinder, and inquiry is made 
whether or not the vision is improved, and also 
whether a correspondingly low + cylinder still 
further improves the vision; if the spheric lens is 
preferred to the cylinder, it is put in the trial- 
frame, back of the cylinder first applied, and the 
same mode of procedure further pursued, testing 
with, a low spheric lens and then a low cylinder 
until the vision can no longer be improved. The 
result is then noted and the examination of the 
other eye commenced in the same manner. 
If, however, neither a + spheric nor a + cylinder 
lens improves the vision, a - spheric and a - cyl- 
inder are used in the preceding manner. It 
sometimes happens that a + cylinder is accepted, 
but further improvement cannot be obtained 
by an advance in the strength of a cylinder, or by 
the addition of a + spheric lens; in such case 
immediately resort to a - spheric lens or a - 
cylinder, placed at an axis at right angles to the 
position at which the + cylinder was preferred. 
Occasionally rotating a cylindric lens of one eye, 
with both eyes corrected and participating in 
vision, will definitely determine a doubtful axis 
better than if the fellow-eye is excluded by an 
opaque disc. 
An exact knowledge of the correct method of 
using the test-lenses can only be obtained by long 
experience; a few other practical points are given 
in the discussion of the various forms of ametropia. 
See Astigmatism, Hyperopia, Myopia Eyestrain. 
Other Methods of Determining Refraction of the 
Eye.-In this discussion the many other ingenious 
methods devised will be left to the numerous text- 
books on ophthalmology. For practical purposes 
it is only necessary to describe the ordinary and 
universally used subjective method with test- 
cards and test-lenses, and the objective methods of 
importance-namely, refraction with the retino- 
scope, with the ophthalmoscope, and the estimation 
of corneal astigmatism by the ophthalmometer. 
See Ophthalmometer, Ophthalmoscopy, Ret- 
inoscopy, Vision (Tests). 
RELAPSING FEVER (Febris Recurrens; Spiril- 
lum Fever; Famine Fever; Seven-day Fever; 
Typhus Icterodes).-An acute infectious disease 
characterized by two or more febrile relapses 
separated by periods of total remission, and 
caused by the inoculation and multiplication of 
the spirochete of Obermeier. 
Etiology.-The specific cause of relapsing fever 
is the Spirochaeta Obermeieri formerly regarded as 
Spirilla of Relapsing Fever from Blood of a Man.- 
(Kolle and Wassermann.) 
a bacterium of the genus spirocheta but now re- 
garded as probably a protozoan parasite-a try- 
panosome. First discovered by Obermeier in the 
blood of cases, it is known by his name. It is a nar- 
row spiral about 0.025 to 0.05 mm. (1/1000 to 1/500 
inch) in length; that is, its length is from 3 to 6 
times the width of a red blood-disc. It is found 
floating among the blood-discs during the fever. 
Before the crisis and in the intervals the organism 
is not found; but small, glistening spherules, 
said to be its spores, take its place. Confirmation 
of the contagious nature of the disease is found in 
the fact that it has been communicated from one 
human being to another by inoculation of blood, 
and to monkeys in the same way. It may be 
supposed that the organism is given off in the 
breath or from the skin. The operation of the 
cause is undoubtedly favored by overcrowding. RELAPSING FEVER 
RESINS 
by filth, and by destitution. Yet the disease is 
not confined to the poorly fed. Neither age, sex, 
nationality, nor season are factors in its causation. 
There is no essential morbid anatomy, and such 
as is found corresponds with that of typhus. Most 
conspicuous is enlargement of the spleen. 
Symptoms.-The period of incubation varies 
greatly, so that it is put down at from 2 to 14 days. 
According to Murchison there may actually be no 
interval between exposure and the invasion. The 
latter is sudden by a chill, fever, intense pain in the 
back and limbs, with dizziness. This abrupt 
invasion is a distinctive feature, and in perhaps 
none of the contagious diseases is it as a rule 
so marked. Exceptionally only is there a short 
deriod of malaise with loss of appetite. On in- 
vasion the temperature rises rapidly and quickly 
reaches 104° F. The patient cannot retain his 
feet and promptly takes to his bed, feeling very 
sick rather than profoundly weak; there may 
be nausea and vomiting and even convulsions in the 
young; the pulse rises rapidly, more rapidly than 
in typhus, reaching 140 on the second day, and later 
150 and 160. The patient may be delirious, but 
the typhoid symptoms are not usually so profound 
as in typhus, and the tongue remains moist. Jaun- 
dice appears in a certain number of cases on the 
third or fourth day, usually in 1 out of every 12 
cases, occasionally as often as 1 in every 4 or 
5. The temperature during the paroxysm fluc- 
tuates slightly, being higher in the evening. 
Sweating and sudamina are often present and 
occasionally petechiaj, but there is no character- 
istic eruption. Rarely, a roseolous rash appears 
in small spots, or it may be a mottling like that 
of typhus, which, however, always disappears on 
pressure, and disappears altogether in 3 or 4 
days, differing in these respects from the similar 
eruption of typhus. Herpes may be present. 
There is occasionally abdominal tenderness in the 
epigastric or iliac region and the enlarged spleen 
may be easily detected, but there are no active 
intestinal symptoms. The liver is also slightly 
enlarged, extending lower than in health. The 
spirillum is to be found in the blood and should 
always be looked for. It may readily be detected 
with a power of 500 diameters without any special 
preparation of the blood, care being taken simply 
to secure a thin film. 
If the invasion of relapsing fever is sudden, its 
termination is not less so. It is by crisis, beginning 
usually with sweating. After 5 or 6 days of un- 
abated fever, sweating sets in, which soon becomes 
profuse, the temperature falls rapidly to normal 
or even subnormal, the various discomforts fade 
away, and in the course of a few hours the patient 
is apparently well. Rarely the crisis may be 
ushered in by a diarrhea, an epistaxis, or the ap- 
pearance of menstruation. The crisis does not 
always take place at the same stage of the disease. 
It may occur as early as the third day or not until 
the tenth, and even the fifteenth, but most com- 
monly on the seventh. While the crisis is ordi- 
narily followed by some relaxation and faintness, 
there soon ensues a rapid recovery of natural and 
healthful feeling. Occasionally, however, the 
depression is greater, and a feeling as of collapse 
occurs, especially in delicate or elderly persons. 
Again, in a week from the crisis-generally on the 
fourteenth day from the primary chill-another 
occurs, or a series of them, with fever, and the parox- 
ysm repeats itself, to be again succeeded by a crisis 
at a somewhat shorter interval. There may be 
a third or even fourth and fifth paroxysm; more 
commonly they are limited to two or at most three. 
Each succeeding attack is shorter than the previous 
one. Occasionally there is no relapse, the disease 
terminating with the first crisis. Convalescence, 
usually rapid, is sometimes prolonged, and the 
duration of the entire illness may be put down 
at from 18 to 90 days, and the patient rarely re- 
turns to work within 6 weeks. One attack does 
not confer immunity from another (Tyson). 
Complications.-Among the complications may 
be mentioned bronchitis, pneumonia, nephritis, 
and hematuria. The spleen may enlarge until it 
ruptures. It may attain a weight of 4 1/2 pounds, 
and may be the seat of infarcts. Albuminuria oc- 
curs as in other fevers characterized by high 
temperatures. Pregnant women usually abort in 
the relapse, and the child, if not still-born, survives 
but a few hours. Postfebrile paralysis may occur, 
and troublesome ophthalmia succeeds in some 
epidemics. 
Diagnosis.-Yellow fever has many points of re- 
semblance, but has a shorter febrile stage, remis- 
sion not so complete, vomiting late and charac- 
teristic, normal spleen, and the late appearance 
of yellow color. 
Remittent fever begins with a decided chill, 
followed by fever and sweats, and not the progres- 
sive rise of temperature until the fifth or seventh 
day. Examination of the blood will reveal a 
different organism from that of relapsing fever. 
Prognosis.-Recovery is the rule, but protracted, 
and decided emaciation results. 
Treatment.-The febrile paroxysm demands 
much the same treatment as typhus: Careful 
nursing; sponging or cool bathing; nutritious, 
easily assimilable food, and stimulation, although 
the latter is less important than in typhus. No 
drug has the power to prevent the recurrence of 
the relapse, although quinin is indicated, and, 
as in other adynamic fevers, is useful as a roborant. 
It is reasonable to expect that acetphenetidin, 
acetanilid, or antipyrin will relieve the muscular 
pains. Should they not suffice, morphin, hypo- 
dermically, can be relied upon. A serum has been 
elaborated from the blood of infected horses and 
the results following its use seem gratifying. 
REMITTENT FEVER.-See Malarial Fevers. 
RENAL CALCULUS.-See Kidney (Stone). 
RESINOL.-A product obtained by the destruc- 
tive distillation of resin. It occurs as a yellowish 
oily liquid, and is used as a solvent for phenol, 
aristol, iodol, camphor, cocain, carbolic acid, 
creosote, phosphorus, and many alkaloids. Its 
physiologic action and uses are those of tar. In 
chronic scaly skin-diseases, especially psoriasis and 
chronic eczema, it is serviceable. 
RESINS (Resinae).-The proximate principles 
called by this name are neither the commercial RESORCINOL 
REST CURE 
resins nor the resins of pharmacy, all of which are 
complex bodies, but include only the chemical 
individuals of resinous character existing in nature, 
as those in copaiba, cannabis, gamboge, guaiac, 
gurjun, etc. Even these, in their commercial 
form, are accompanied by other principles. It 
is difficult to define the resins correctly, but they 
are generally considered to be oxidation products 
of hydrocarbons, such as terpenes. They are 
mostly brittle, amorphous, uncrystallizable solids, 
insoluble in water, but soluble in alcohol, ether, 
chloroform, benzin, etc. Most of them are of 
acid character, combining with alkalies to form 
a kind of soap, these "resin-soaps" being soluble 
in water and giving up their resins again to the 
action of acids. They soften or melt when heated 
and solidify again on cooling. 
The substances ordinarily called resins are 
usually classified as follows: 
True resins are hard, compact products of oxi- 
dation, and are made up chiefly of resin acids. 
Such are copal, damar, mastic, sandarach, dragon's 
blood, gum-lac and amber. Gum-resins are 
natural mixtures of gum and resin. When they 
are rubbed up with water the gummy matter 
dissolves and the resin is suspended in the form of 
an emulsion. Such are olibanum (frankincense), 
myrrh, ammoniac, asafetida, galbanum and 
tragacanth. Oleo-resins include all mixtures of 
volatile oils and resins of whatever consistency, 
also the balsams or mixtures of resins with benzoic 
and cinnamic acids. Such are copaiba, crude 
turpentine, storax, and the true balsams-benzoin, 
balsam of Peru and balsam of Tolu. See Oleo- 
resins. Pharmaceutical resins are solid prepara- 
tions obtained by precipitating the resinous prin- 
ciples of plants from their alcoholic solutions by 
the agency of water. They differ from alcoholic 
extracts in containing only those principles which 
are soluble in alcohol and insoluble in water, while 
the extracts contain all principles which are soluble 
in alcohol. Including resina itself, which is the 
residue left after distilling off the volatile oil from 
turpentine, there are 4 official resins: Resina; R. 
Jalapse; R. Podophylli; R. Scammonii. 
RESORCINOL.-C0H4(OH) 2. Metadioxyben- 
zene, a substance produced from different resins, 
and from umbelliferous gum-resins on fusion with 
caustic potash. It is isomeric with hydroquinon. 
It crystallizes in colorless rhombic prisms or plates, 
melts at 118° C., and boils at 276° C. It resembles 
carbolic acid in many of its properties, but it is 
less toxic; it is odorless, antiseptic, and a powerful 
germicide. It is valuable chiefly as an antipyretic 
in malarial fevers, and locally as a lotion in diph- 
theria and certain skin-diseases. Dose, 1 to 10 
grains; as an antipyretic, 5 grains every 2 hours, 
or 15 to 30 grains not repeated. It is readily 
soluble in water, alcohol, and ether. In dyeing 
it yields a fine purple-red coloring-matter, and 
several other dyes of commercial importance. 
Poisoning.-Toxic doses (15 grains to each 35 
ounces of weight) paralyze the motor tracts in the 
spinal cord, but do not affect the general sensibility. 
It is eliminated chiefly by the urine, which it colors 
a bluish-violet hue. The best test of its presence 
is the solution of the perchlorid of iron, which 
produces with it a dark-violet, almost black, color. 
Atropin and other cardiac and respiratory stimu- 
lants, cerebral excitants, and agents that raise the 
arterial tension are physiologically antagonistic. 
In subacute or chronic eczema: 
1$. Resorcin, 
Zinc oxid, 
each, 5 j 
Cold cream, 5 x. 
Apply to the affected parts twice daily. 
RESPIRATION.-See Artificial Respiration, 
Chest (Examination). 
REST CURE.-What is known as the "rest cure" 
or "rest treatment" was perfected in this country 
by S. Weir Mitchell. The treatment is especially 
directed toward the restoration of the vitality of 
the feeble or overworked by a combination of iso- 
lation from friends, rest in bed, and excessive or 
forced feeding, together with the thorough use of 
massage and electricity. The cases best suited for 
this treatment are those in which an enfeebled 
condition has resulted from an infectious disease, 
from pneumonia, etc., those of chronic dyspepsia, 
malarial toxemia, neurasthenia, spinal irritation, 
and hysterics. 
By this method an entire change in surroundings, 
diet, and mode of life is instituted with the hope 
that "routine" may be combated and mental 
activity reduced to the minimum. From 4 to 6 
weeks absolute rest in bed is required in most cases. 
During the first week only milk is allowed, 4 
ounces of which are given every 2 hours and grad- 
ually increased until 10 to 12 ounces are given 
every 3 hours. Stimulating drugs are prohibited, 
the dominant idea being to place the whole ner- 
vous system in a state of profound rest. Nutri- 
tive tonics and digestants only are permitted. 
To counteract depression and exhaustion, which 
necessarily ensues from confinement to bed, mas- 
sage and electricity are employed daily. Proper 
periods are chosen for massage, usually selecting 
some period an hour or two after meals. The 
patient lying in bed, the operator, first beginning at 
the toes, carefully kneads the parts in all directions; 
the muscles of the foot are then similarly treated, 
then the ankles, legs, and body, while at the same 
time the joints are bent in all directions. 
It is essential that the anatomic relations of the 
muscles should be known in order that passive 
exercise of each may be encouraged. From 20 min- 
utes to 1 hour are spent in this exercise. In treat- 
ing the larger muscles they should be grasped 
firmly, pressed downward, and then kneaded. All 
massage movements should be in the direction of 
the heart, in order that the circulation may be 
naturally stimulated. The form of electricity 
employed is the faradic current of very moderate 
intensity with a slow interrupter. A space of 
4 or 5 inches should interpose between the two 
poles, and sufficient time allowed to elapse in order 
that a full muscular contraction may ensue. 
After the arms and legs have been treated in this 
manner for some time, the rapid interrupter is used; 
one pole is applied to the neck, the other to the RETENTION OF URINE 
RETINA, DISEASES 
heel for 10 minutes, then to the other heel for an 
equal length of time. Forty minutes should be 
given to this application. 
Proper mental and bodily habits are demanded. 
The patient is aroused about 7 a. m., given a cup of 
coffee, tea, or cocoa, and subsequently a cold bath 
while in bed, bathing each limb alternately; an 
hour later a generous breakfast is allowed, and at 
10.30 milk, broth, or soup is given. At 11 a. m. 
massage is employed, followed by a glass of milk. 
At 1 p. M. a liberal dinner is given, and at 3 p. m. 
liquid food. At 6 p. m. a moderate supper is 
served, and at 9 p. m. a glass of milk. Frequently, 
a dry scrub-bath may be given before the patient is 
allowed to sleep. 
In 3 or 4 weeks the patient may be allowed to 
sit up out of bed for an hour or two, and a few days 
later may take excursions out of doors for from 
a half or three-quarters of an hour. At the end 
of 6 weeks the patient is advised to spend several 
months at the seashore, and, if possible, a short 
period in the mountains. 
RETENTION OF URINE.-See Urine (Reten- 
tion). 
RETINA, DISEASES.-Hyperemia of the retina 
is detected by an increase in the size of the retinal 
vessels, particularly noticeable over the disc, which 
appears pinkish in contrast. It is caused by stasis 
or irritation. In stasis-hyperemia the thickness of 
the veins in comparison with the arteries is noticed. 
Irritation-hyperemia usually accompanies inflam- 
mation of some other portion of the eye, or it 
may be a sign of eye-strain. It is quite common 
in persons with some uncorrected refractive error 
or muscular imbalance, who use their eyes to 
excess. 
Treatment should be directed to correction of 
any ametropia or muscular trouble, and the eye 
should be put at rest and shielded with protective 
glasses. If the hyperemia is supposed to be a 
local expression of cerebral congestion, the treat- 
ment for the latter affection should be instituted. 
Retinal hemorrhage is seldom an independent 
affection, but is usually associated with some dis- 
ease or injury of the retina; or it may be the result 
of some condition provocative of hemorrhage in 
any other organ, such as atheroma of the arteries, 
hypertrophy of the left ventricle, scorbutus, 
hemorrhagic purpura, nephritis, diabetes, per- 
nicious anemia, etc. In such conditions the im- 
mediate cause may be muscular strain, violent 
coughing, or sudden change in the intraocular 
tension after operation. Hemorrhage following 
occlusion of the retinal vessels will be mentioned 
later. 
Diagnosis with the ophthalmoscope is easy if 
the media are clear and if the remaining portion of 
the retina and disc is unaffected. In such a case 
a fresh clot appears as a bluish-red blotch on a 
white background; or, if the clot is old, a brownish- 
red blotch is seen; or the only remnants of the 
hemorrhage may be a spot of yellowish-white 
degeneration, perhaps associated with pigment 
deposits. The hemorrhage is flame-shaped when 
in the internal layers, rounded when in the external 
layers, and massive when between the retina and 
hyaloid membrane of the vitreous (subhyaloid). 
If other blotches are seen in the retina and the 
whole fungus is hazy, the condition is called 
hemorrhagic retinitis. 
Prognosis depends on the cause and recurrence 
of hemorrhages; unfortunately, the prognosis of 
affections causing retinal hemorrhage is usually 
bad. The amount of visual disturbance depends 
on the location and size of the clot. Hemorrhage 
in the macula is serious. Multiple hemorrhages 
may cause a glaucomatous condition, producing 
blindness. 
Treatment must be directed to the general cau- 
sative condition. Patients should be put to bed 
and the eyes bandaged. Congestion may be 
relieved by leeches or dry cups to the temples. 
Mercurials and iodids, together with diaphoresis, 
may promote absorption. 
Retinitis.-It is probable that idiopathic retini- 
tis never occurs. Inflammation of the retina is 
generally due to some disease of the general system, 
such as syphilis, renal disease, diabetes, leukemia, 
etc. In cases of prolonged exposure or excessive 
use of the retina the resultant affection is more in 
the nature of a functional trouble than a true 
inflammation. Retinitis may be due to an exten- 
sion of inflammation from the neighboring struc- 
tures, principally the ciliary body, choroid, and 
optic nerve. Panophthalmitis produces an im- 
mediate suppuration of the retina. 
The subjective symptoms of retinitis are usually 
dimness of vision, scotoma, metamorphopsia, etc. 
The objective symptoms elicited by the ophthalmo- 
scope are sometimes quite characteristic of the 
causal trouble, although differential diagnosis is at 
times very difficult. However, the condition dis- 
covered is often a valuable indicator in substanti- 
ating systemic evidence of the general disease, and 
is an important factor in prognosis. 
Albuminuric retinitis is almost always bilateral, 
although a number of unilateral cases are recorded. 
The light-sense, color-sense, and visual field are 
usually undisturbed. Dimness of vision progresses 
slowly, and sometimes it is difficult for the pa- 
tients to count fingers. This affection often ac- 
companies the nephritis of pregnancy. Uremia, 
coincident with renal disease, may cause complete 
blindness, but this cannot be attributed to retin- 
itis, but rather to a transient effect upon the 
cuneus lobe by the uremic poison. 
Ophthalmoscopic changes differ in the various 
stages, although they are most marked in advanced 
renal disease. The changes in the fundus are 
generally confined to the posterior pole and region 
adjoining. Hyperemia is at first noticed, but in 
the advanced disease white spots or patches are 
seen about the papilla, and later fine white dots are 
noticed grouped about the macula in the shape of a 
star with the fovea in the center. Finally, hemor- 
rhages and fatty degeneration, with paleness of the 
disc and contraction of the vessels, may occur just 
before death. In some cases, instead of white 
spots, there may be numerous widespread hemor- 
rhages, or, again, only congestion and simple red- 
ness of the disc. 
Prognosis.-The exact relation between retinitis RETINA, DISEASES 
RETINA, DISEASES 
and the coincident renal disease is not definitely 
established. However, it may usually be said that 
a definite case of albuminuric retinitis will have 
a fatal issue within 2 or 3 years, although the visual 
disturbance may not increase, and may even im- 
prove in fatal, chronic cases. Cases have been 
observed in which the patients have lived from 5 
to 10 years after typical albuminuric retinitis had 
been established. In interstitial nephritis par- 
ticularly, retinitis is a serious sign. After recovery 
from acute nephritis an associate retinitis may 
clear up and the vision become normal. The prog- 
nosis of both fife and vision is better in the albu- 
minuric retinitis of pregnancy, and in cases in 
which only one eye becomes involved. 
Treatment must be that of the original disease. 
In hemorrhagic cases, rest, bandaging of the eyes, 
and possibly the instillation of atropin, in weak 
solution (1 grain to 1 ounce), are advisable. The 
appearance of albuminuric retinitis in pregnancy 
is regarded by many as an indication for the induc- 
tion of abortion. See Nephritis. 
Diabetic retinitis is often indistinguishable from 
albuminuric retinitis by the ophthalmoscope alone. 
The diagnosis can only be made by the test for 
glycosuria. The prognosis is probably not so bad 
as in the foregoing disease, and dietary and 
hygienic treatment may establish a cure. 
Syphilitic retinitis is a diffuse instead of a local 
inflammation, as in the preceding diseases, and 
may be unilateral or bilateral. A general cloudi- 
ness, most apparent at the optic disc, and gradu- 
ally shading off into the periphery of the fundus, is 
noticed. White lines may be observed along the 
course of the blood-vessels. There are numerous 
dust-like opacities in the vitreous. Hemorrhages 
are less frequent than in the preceding forms. 
The treatment is purely constitutional. 
Leukemic retinitis is characterized by the pale- 
yellow appearance of the fundus, always bilateral. 
There is a marked tendency toward hemorrhages; 
sometimes circular white clots and prominent 
blood-bordered spots are seen at the periphery of 
the retina. Diagnosis should be substantiated 
by microscopic examination of the blood. The 
treatment is that of leukemia. 
Retinitis of pernicious anemia presents an ede- 
matous condition of the retina, diffuse retinitis, 
with distended veins and pallid blood. The disc 
appears dirty greenish-white, against a yellowish 
eye-ground. 
Retinitis Pigmentosa.-A pigmentary degenera- 
tion of the retina sometimes found in descendants 
of consanguineous marriages, or of syphilitic par- 
ents. It occurs commonly in members of the same 
family. 
Symptoms and Diagnosis.-The chief subjective 
symptoms are night-blindness, due to the reduced 
sensitiveness of the retina; concentric contraction 
of the field of vision, often coupled with nystag- 
mus, causing the patient great inconvenience from 
inability to find his way, although his central 
vision may be acute. The constant bowing of the 
head in walking is a characteristic sign. The fun- 
dus has a very characteristic appearance. The disc 
is yellowish and its edge is somewhat obscured, and 
the vessels are narrowed, accompanied by fine 
bands, and fade off into the periphery. Dark 
streaks of pigmentation, beginning at the periphery, 
trail over the fundus, and gradually progress to- 
ward the macula. In appearance these have been 
compared to the Haversian bone-canals. Cases of 
retinitis pigmentosa without the distinctive pig- 
mentation are occasionally found. There is 
evidence of pigment-atrophy at the periphery, 
slightly subnormal night-vision, narrowed color- 
field, etc. 
Treatment is useless. All that can be done is to 
keep the patient in good health and spirits, and 
surround him with hygienic conditions conducive 
to the arrest of any degenerative process. 
Thrombosis and Embolism of the Retinal Vessels. 
-Embolism of the central artery of the retina is 
rare. Both the ophthalmic and central retinal 
arteries branch at right angles from their parent 
stems, and an embolus is easily swept by them. 
The characteristic subjective symptom is sudden 
blindness in one eye, probably after some slight 
exertion. There may be temporary improvement 
during the succeeding weeks, but the prognosis is 
very unfavorable. The differential diagnosis be- 
tween thrombosis and embolism with the ophthal- 
moscope is sometimes difficult. Hemorrhages are 
more numerous in thrombosis, and there is intense 
swelling of the nerve and retina. There is pallor of 
the disc and retina in embolism, and marked 
diminution in the size of the vessels. The veins 
become tortuous and very irregular. The central 
portion of the retina becomes hazy and grayish, 
the macula standing out in sharp contrast by its 
maintenance of the normal red color, the classic 
''cherry-red spot," supposed to be due to the non- 
existence of the nerve-fiber layer at the fovea, al- 
lowing the choroidal vessels to show through. 
Finally, atrophy of the disc and retina ensue, and 
the vessels become obliterated and replaced by 
white streaks. Involvement of only a branch of 
the central artery is followed by an anemic and 
degenerated sector-like area supplied by the af- 
fected artery. The diagnosis should be confirmed 
by the discovery of some systemic source of em- 
bolus or thrombus, such as endocarditis, or other 
organic heart affection, phlebitis, pyemia, etc. 
Treatment is of little avail; but sometimes in 
very recent cases it may be possible to remove the 
embolus by massage of the eyeball, or by reduc- 
tion of the internal tension, as by sclerotomy. 
General treatment is, of course, indicated. 
Detachment of the Retina.-The most common 
cause is disease of the choroid consequent upon 
myopia of high degree. Chronic inflammation of 
the eyeball or of the retina alone, fluid effusions or 
hemorrhage between the retina and choroid, in- 
juries, new growths, diseases of the vitreous, re- 
moval or dislocation of the lens, and parasites, are 
other causes. Any condition in which the intra- 
ocular tension is suddenly lowered-as, for in- 
stance, by the rapid escape of vitreous after a cor- 
neal section-predisposes to retinal detachment. 
Symptoms and Diagnosis.-The premonitory 
signs are flickerings and the appearance of dazzl- 
ing sparks before the eyes, and attacks of momen- RETINA, DISEASES 
RETINOSCOPY 
tary blindness. The detachment takes place sud- 
denly, and the field of vision is obscured by what 
seems to be a dark cloud before the eyes. The de- 
tachment is only partial at first, and the retina is still 
nourished by its own vessels, its functions being 
impaired rather than destroyed. Naturally, the re- 
fractive condition of the eyes is more hyperopic, 
but as the detached portion of the retina con- 
stitutes irregular folds, which constantly move 
with every movement of the eye, metamorphopsia 
and other anomalous visual disturbances are pres- 
ent. By the ophthalmoscope there is absence of 
the red reflex in the region of the detachment. In 
advanced cases a bluish-gray curtain is seen float- 
ing freely in the vitreous, and many even be seen 
by the naked eye. The picture may be confused 
by vitreous opacities, which frequently accompany 
this condition. 
Prognosis is dependent on the cause. If caused 
by intraocular tumor, the case may be considered 
hopeless. If due to pronounced myopia, one eye is 
usually attacked after the other, and blindness is 
unavoidable. In the other conditions the prog- 
ress of the detachment may possibly be arrested, 
but we can hardly hope for improvement, although 
instances of alleged reattachment without treat- 
ment have been reported. 
Treatment consists of prolonged rest in bed with 
protection of the eyes from light by a pressure-band- 
age. Antiphlogistic measures should be adopted; 
diaphoresis with the salicylates, or by hypodermic 
injection of pilocarpin, may prove of benefit. 
Several cases are reported to have been cured by a 
course of tuberculin treatment. See Tuberculo- 
sis (Ocular). 
The operative treatments that have recently 
been recommended are puncture through the 
sclerotic, allowing escape of the subretinal fluid, 
injection of an artificial vitreous in front of the 
prolapsed retina, or injection of a few drops of 
iodin in the vitreous. The real value of these 
measures is doubtful. 
Glioma of the Retina.-A malignant tumor, soft 
and highly vascular, developing in the retinal con- 
nective tissue (sometimes designated neuroglia). 
Symptoms.-It occurs chiefly in children from 
1 to 4 years old. On account of the youth of the 
patient and the absence of pain, the early subjec- 
tive symptom-visual disturbance-escapes un- 
noticed. The child may be totally blind for some 
time without the parents' knowledge, attention to 
the eye first being called by the bright shimmer in 
the pupil, the so-called "cat's eye." In the first 
stage of the disease the ophthalmoscopic examina- 
tion shows a yellowish prominence surrounded by 
small nodules, toward which dilated retinal vessels 
converge. In the second stage there is probably 
increased tension, and the growth begins to push 
its way forward, carrying the retina, lens, and iris 
with it. The cornea and the aqueous may become 
opaque, and the conjunctival vessels intensely con- 
gested. Internal inflammation progressively in- 
creases, and the tumor may escape through a 
perforation in the cornea or penetrate the sclera, 
and appear as a spongy bleeding mass between 
the lids. The final stage is extension along the 
optic nerve, or metastasis to the neighboring 
structures. 
Diagnosis is easy after the second stage is reached. 
In their early stages suppurative choroiditis or hy- 
alitis may produce symptoms so closely resembling 
glioma that they have been called pseudoglioma. 
However, in choroiditis inflammation precedes the 
blindness, and the eye is soft. If there is doubt 
as to the diagnosis, the case should be treated as 
glioma, to prevent an error, which may prove 
fatal. 
Prognosis.-Unfortunately, it is usual for the 
child to be brought for treatment after the disease 
has progressed sufficiently to cause the "cat's eye" 
or other prominent objective symptoms, and it 
may be too late even to save the child's life. There 
is absolutely no hope of preserving the affected eye. 
Treatment.-Not only should the affected eye 
be immediately enucleated, but the optic nerve 
should be divided as far back as possible, and if 
there is the slightest sign of invasion of the orbital 
tissues, they must be removed and the orbit 
cauterized. 
RETINOSCOPY (Shadow-test).-The method of 
estimating the refraction of an eye by reflecting 
into it rays of light from a plane or concave mirror, 
and observing the movement that the retinal 
illumination makes by rotating the mirror. To 
avoid confusion, the description of retinoscopy 
that follows will apply to the plane mirror, which 
is to be preferred to the concave mirror, as it is 
decidedly more satisfactory for general use and 
convenience. 
The principle of retinoscopy is the finding of the 
point of reversal, or myopic far-point. Should 
the eye under examination be emmetropic or 
hyperopic, it must be given an artificial far-point. 
Advantages.-Of all the objective methods of 
refraction, retinoscopy in the hands of the expert 
is the most exact, but, like all objective methods, 
its results should, when possible, be confirmed 
with the trial-lenses. 
Retinoscopy offers the following advantages: 
1. The character of the refraction is quickly 
diagnosed. 
2. The refraction is estimated -without the verbal 
assistance of the patient. 
3. No expensive apparatus is necessarily re- 
quired. 
4. Little time is taken to estimate the refrac- 
tion. 
5. It is of inestimable value in the young, in the 
feeble-minded, the illiterate, in cases of amblyopia, 
nystagmus, and aphakia; and in such cases the 
retinoscopic correction may be ordered. 
The retinoscope, or mirror, is of varying form 
and size. The one recommended is the small 
plane mirror, 2 cm. in diameter, on a 4 cm. metal 
disc, with a 2 mm. sight-hole at the center of the 
mirror, made by removing the silvering and not 
by cutting a hole through the glass. 
The light should be steady, clear, and white, 
and secured to a movable bracket. For general use 
the Argand burner is best. As only a small portion 
of the flame is used, it is necessary to cover most 
of it with a screen. RETINOSCOPY 
RETINOSCOPY 
The screen, or cover-chimney, is made of thin 
asbestos and of sufficient size to fit easily over 
the glass chimney of the Argand burner. The 
opening used, generally 1 cm. in diameter, should 
be opposite to the brightest part of the flame. An 
asbestos cover-chimney is used in preference to 
metal, as it intercepts most of the heat. 
The room for retinoscopy must be darkened, and 
the darker the better; all sources of light except the 
one in use must be excluded. This must be insisted 
upon, as darkness offers the best contrast to the test. 
Position of the Light and Mirror.-The rays of 
light coming out of the opening in the light-screen 
should be 5 or 6 inches in front and to the left of 
the observer, so that the rays may pass in front of 
the left eye and fall upon the mirror held before the 
right eye, thus leaving the observer's left eye in 
comparative darkness; or this may be reversed if 
the observer is left-handed. The observer should 
keep both eyes wide open. 
In order to see the movements distinctly the 
observer should wear his correcting glasses, but 
need not make any note of his accommodation as 
in using the ophthalmoscope. 
The patient must have his accommodation 
thoroughly relaxed with a reliable cycloplegic, and 
be comfortably seated in front of the observer, 
preferably at 1 meter distance, with his vision stead- 
ily fixed on the observer's forehead just above the 
mirror; or, even better, the patient may concen- 
trate his vision on the edge of the metal disc of 
the mirror, but never directly into the mirror, as 
that would soon irritate and compel him to close his 
eye. In cases of squint it is particularly necessary 
to cover one eye while its fellow is being refracted. 
To Find the Point of Reversal.-In observing the 
retinal illumination, the most important thing 
to study is the direction in which it moves, or 
whether it moves at all. For example, having 
determined at 1 meter distance, with a + 2.00 
D. lens before the patient's eye, that the retinal 
illumination moves in the same direction in which 
the mirror is tilted, and then, substituting a + 
2.25 D., and the illumination appears to move in 
the opposite direction, the observer will know at 
once that the difference in the strength of these 
lenses, + 2.12 D., would bring the emergent rays 
to a focus on his retina and that no movement 
of the retinal illumination could be made out, 
and this point, when found, is the point of reversal 
or artificial far-point. 
Emmetropia.-The rays of light from an emme- 
tropic eye proceed parallel, and by reflecting the 
rays of light into such an eye from a distance of 1 
meter the observer sees a small bright retinal 
illumination, which moves rapidly in the same 
meridian through which the light is passed. By 
placing a + 1.00 D. lens in front of such an eye 
all apparent movement in the pupillary area ceases, 
showing that the + 1.00 D. has bent the emergent 
rays and brought them to a focus on the observer's 
retina. This +1.00 D. has made this emmetropic 
eye myopic just 1 D., so that in taking the patient 
thus refracted from the dark room to test his vision 
at 6 meters, this 1 D. of artificial myopia must be 
removed, thus proving the emmetropic condition. 
Hyperopia.-In hyperopia the same conditions 
hold true as in emmetropia. For example, having 
placed a + 3.00 D. in front of the eye and found 
that the previously slow movement with the mir- 
ror has ceased, and substituting a + 3.25 D. makes 
it move opposite, it will be known at once that the 
+ 3.00 D. was the correcting glass for 1 meter; 
or, in other words, that the original divergent 
rays proceeding from the eye were bent by the + 
3.00 D. and brought to a focus on the observer's 
retina. Two D. of this + 3.00 D. would have 
made the eye emmetropic, but the additional 
+ 1.00 D. made the eye myopic just that amount, 
and taking the patient from the dark room this 
1.00 D. of artificial myopia must be taken from the 
dark-room result, which would leave + 2.00 D. 
as the amount of the hyperopia. 
Myopia.-The rays of light from a myopic eye 
always proceed convergently, and to the observer 
seated at 1 meter distance the retinal illumination 
appears to move opposite to the direction in which 
the mirror is moved if the myopia exceeds 1 D., 
and to move with the movement of the mirror if the 
myopia is less than 1 D. An eye that is myopic 
just 1 D. has its emergent rays focusing at 1 meter, 
and the observer with his eye at this point does 
not recognize any apparent movement in the 
pupillary area. 
For example, an eye that is myopic 4.00 D. 
has its emergent rays focusing at 10 inches, and the 
observer at 1 meter has the apparent movement 
of the retinal illumination moving opposite to the 
movement of the mirror. If a - 3.00 D. is placed 
in front of this eye, the emergent rays then focus 
at 1 meter, at which point the observer does not 
appreciate any movement of the retinal illumina- 
tion. It will thus be seen that the eye that is 
myopic more than 1.00 D. retains 1 D. of its 
myopia when tested at 1 meter, and this 1.00 D. 
must be supplied in taking the patient from the 
dark room to test his distant vision. 
If the observer will remember to always use a 
plus lens when the retinal illumination moves 
with the movement of the mirror, and a minus 
lens when it moves opposite, and allow for the 
1. D. of myopia when working at i meter, he will 
have the following rule to guide him: namely, 
to add a minus i.oo D. to the dark-room result in 
every instance-i. e., 
Dark room 0.00 D. + 0.25 D. + 0.50 D. + 0.75 D. + 1.00D. 
add -1.00 -1.00 -1.00 -1.00 -1.00 
Result -1.00 -0.75 -0.50 -0.25 -0.00 
Regular Astigmatism.-The presence of this 
condition when looking in the eye before any 
neutralizing lens has been placed in position, can 
be determined when a band of light is seen extend- 
ing across the pupil, or when it is possible to note a 
difference in the rate of movement of the retinal 
illuminations of any two meridans at right angles 
to each other. If the spheric error is high and 
the cylinder a low one, then it will not always be 
possible to recognize the characteristic band of 
light (astigmatism) until the approximate neu- 
tralizing sphere has been added. 
The axis subtended by the band of light after 
the requisite sphere has corrected the meridian of RETROFLEXION 
RHEUMATISM, ACUTE ARTICULAR 
least ametropia is the axis for the cylinder in the 
prescription to be given. 
The better way to neutralize cases of astigma- 
tism is to use spheric lenses in preference to cylin- 
ders, for by so doing the difficulty of placing cyl- 
inders on the exact axis is avoided; for example, 
in the following formula, +S. 2.00+ C. 1.00 axis 
90 degrees, it will be found that a + 3.00 sphere in 
the dark room will correct the 90 degrees meridian 
and partly correct the 180 degrees meridian; and 
that a + 4.00 sphere will correct the 180 degrees 
and overcorrect the 90 degrees meridian, making 
a difference in the strength of the two spheres 
employed of 1.00 D., which is the amount of the 
cylinder required. After thus obtaining the 
result, the observer may, if so disposed, confirm 
it by placing the spherocylinder combination. 
Irregular Astigmatism.-This condition is either 
in the cornea or lens, generally in the former, mak- 
ing it difficult in any instance to study the refrac- 
tion, as the reflex is more or less obscured by areas 
of darkness, so that to study the condition the 
observer may have to change his working distance 
toward or from the eye. The kinetoscopic pic- 
ture obtained by moving the mirror so as to make 
the light describe a circle around the pupillary 
edge of the iris is quite diagnostic of the corneal 
condition. Whatever result is obtained, the 
observer must take care to refract in the area of 
the cornea that will correspond to the small pupil 
when the effects of the cycloplegic pass away. 
It is best in these cases to retain the correction 
found as a guide in a postcycloplegic manifest 
refraction. 
Conic Cornea.-In this condition the observer 
is impressed at once with the bright, round, cen- 
tral illumination that moves opposite to the 
movement of the mirror, the peripheral movement 
being with the mirrow, unless the margin is myopic 
also, but of less degree. The best way to refract 
a case of this kind is to follow the suggestion given 
for refracting cases of irregular astigmatism. 
RETROFLEXION.-See Uterus (Retrodis- 
placements). . 
RETROPERITONEAL TUMORS.-There are 
certain rare tumors which arise behind the peri- 
toneum, having a fixed attachment to the back of 
the abdomen and the intestines in front. Among 
these may be included kidney, suprarenal, pelvic, 
and pancreatic tumors, which are elsewhere de- 
scribed. Of rarer occurrence are the retroper- 
itoneal lipoma, cysts of obscure origin, whether 
multilocular or dermoid, and lymphadenomatous 
and lympho-sarcomatous tumors of the lymphatic 
glands. The diagnosis of such conditions can only 
be completed by exploration, when it has been 
found possible in simple cases to shell them out 
(Spencer and Gask). 
RETROPHARYNGEAL ABSCESS.-A b s c e s s 
behind the pharynx or esophagus. It is due to 
caries of the cervical vertebrae, or, more rarely, to 
suppuration of the retropharyngeal lympathic 
glands. Again, it may have an idiopathic origin, 
as is the case with scrofulous, tuberculous, and 
rachitic children. See Spine (Caries). 
Symptoms.-At first there is difficulty in swal- 
lowing, and to this are soon joined stiff neck, ten- 
derness of the cervical vertebrae, and the snuffling 
voice. Later, the head is bent strongly backward 
as far as possible to prevent dyspnea; respiration 
becomes difficult and stertorous, but not whist, 
ling, as in croup, while the facial muscles twitch- 
and speech is unintelligible. The posterior wall 
of the pharynx, at first only reddened and some- 
what swollen, soon evidently protrudes as a 
fluctuating tumor, which sometimes crowds for- 
ward the uvula. Finally, the abscess opens, and 
an enormous quantity of pus is poured forth into 
the mouth, and if this happens during sleep, the 
pus may flow down into the larynx and result 
possibly in suffocation. 
Prognosis is serious, though not necessarily fatal. 
Treatment.-The patient should be put to bed 
and small pieces of ice used locally. Timely inci- 
sion must be employed after the abscess forms, 
in consequence of suppuration of the lymphatic 
glands; but if the abscess arises from caries of a 
cervical vertebra, incision must be delayed until 
there is real danger from suffocation. After 
opening, rest in bed, lying on the back, for months 
is necessary. lodid of iron may be prescribed. 
RETROVERSION.-See Uterus (Retrodis- 
placements). 
RHACHITIS.-See Rickets. 
RHAGADES.-Linear cracks or fissures in the 
skin, whether due to injury or to disease. They 
are most frequently seen on the palmar and 
plantar surfaces of the hands and feet, at the 
angles of the mouth, at the anus, and at the flex- 
ures. They are painful on movement. They are 
often the early manifestations of congenital 
syphilis, the secretions from these lesions being 
very virulent, and constitute a frequent source of 
infection. 
RHAMNUS PURSHIANA.-See Cascara 
Sagrada. 
RHATANY.-See Krameria. 
RHEUM.-See Rhubarb. 
RHEUMATISM, ACUTE ARTICULAR. 
Synonyms.-Rheumatic fever, inflammatory 
rheumatism. 
Rheumatism is an acute infectious disease char- 
acterized by high fever, inflammation of the large 
joints, acid sweats, and a disposition to cardiac 
involvement. 
Etiology.-No specific bacterium has yet been 
discovered and the distinct causative factor is 
still unknown. There is evidence of some severe 
poison circulating in the system, having a predi- 
lection for the joints, endocardium, and other 
serous membranes. 
Heredity, damp climate with sudden changes 
in the temperature, exposure to the cold and wet, 
lowered vitality, are all conducive to rheumatism. 
It is a disease of young adults and has a tendency 
to recur. Of the different theories that have been 
advanced as to the causes of rheumatism may be 
mentioned (1) metabolic,. (2) nervous, and (3) 
germ theory. Most authorities at the present 
time admit that the disease is infectious. 
Various microorganisms have been isolated 
from the exudate of the joints of rheumatic RHEUMATISM, ACUTE ARTICULAR 
RHEUMATISM, ACUTE ARTICULAR 
patients, which have caused arthritis and endo- 
carditis in lower animals. Probably, as Flexner 
and Barker have suggested, acute articular rheu- 
matism may be caused by the infection of the 
blood by any one of several species of pyogenic 
organisms, at a time when the conditions were not 
favorable to the development of a general septice- 
mia, but which may produce an inflammation of one 
or more serous membranes; hence may occur a peri- 
carditis, pleurisy, or peritonitis of rheumatic origin. 
H. C. Wood, Gurich, etc., have shown that 
suppurative conditions in the tonsils or teeth 
may be the fundamental cause of acute articular 
rheumatism and other general conditions. 
Other affections, such as scarlet fever and gonor- 
rhea, are associated with a synovitis which closely 
resembles ac"te rheumatism, but are due to the 
specific cause of each of those diseases, and are not 
truly rheumatic. 
Pathology.-The membranes and ligaments 
show a high grade of inflammation, being red- 
dened, swollen, and there is an effusion of albumin- 
ous fluid into the joint-cavity, containing many 
leukocytes and flakes of fibrin. The inflammatory 
process producing an increased amount of fibrin 
in the circulating medium is one of the marked 
characteristics of this disease. 
Usually, the attack ends in recovery, but there 
may be a hyperplastic proliferation of the synovial 
membrane, fibrous metaplasia of the cartilage, 
and fibrocartilaginous ankylosis of the joint. 
The blood changes in rheumatism are very 
marked. Rapid anemia develops early and the red 
cells may show a loss of 1,500,000 per cubic milli- 
meter; there is a corresponding loss of the hemo- 
globin, which may be reduced to 50 percent; 
leukocytosis is the rule, and the white blood-cor- 
puscles may run as high as 39,000 per cubic milli- 
meter. The fibrin is greatly increased. Lactic 
acid is in excess. 
Symptoms and Clinical Course.-The onset is 
usually quite sudden, although there may have 
been a history of anorexia, sore throat, pains in the 
affected parts, or a general body "ache." The 
inflammatory process first attacks the larger joints, 
which become reddened, swollen, and excessively 
tender. Often the inflammation may subside 
quickly in one joint to attack another. The parts 
most often affected are the joints of the knee, el- 
bow, shoulder, wrist, and ankle. Occasionally, 
however, one joint alone is involved. There is a 
sudden onset of high fever, 103° to 104° F., and the 
pulse is usually greatly accentuated. With the 
onset of fever acid sweats occur, and the patient 
may be bathed with the excretion almost constant- 
ly. The sour odor is quite characteristic. The 
urine, as in gout and lithemia, is high-colored, 
scanty, and loaded with an excess of uric acid and 
urates. 
Complications.-(1) Hyperpyrexia; (2) endo- 
carditis (very common); (3) pericarditis; (4) myo- 
carditis; (5) pneumonia; (6) pleurisy; (7) cerebral 
symptoms, as delirium, convulsions, meningitis; 
(8) cutaneous symptoms-scarlatiniform rash, 
urticaria, purpura; (9) rheumatic nodules. (10) 
peritonitis. 
Sequels.-Chorea, acute nephritis, exophthalmic 
goiter and chronic joint changes. 
Diagnosis.-The following table illustrates the 
characteristic points of the affections likely to be 
confused with rheumatism: 
Gout. 
Septic Abthritis. 
Osteomyelitis. 
1. Occurs late in 
•1. Septic focus, 
1. History of long- 
life. 
tending to suppu- 
continued pain, 
2. Fever not high. 
ration, present. 
Onset slower. 
2. Hyperp y r e x i a 
which is worse at 
night. 
2. Moderate fever. 
3. No acid sweats. 
not marked. 
3. No acid sweats.. 
3. Acid sweats ab- 
4. Affects small 
joints. 
5. Heart-lesions 
rare. 
sent. 
4. Often affects long 
bones. 
5. Heart-lesions rare. 
Other forms of infectious arthritis such as 
scarlatinal, gonorrheal, and also tuberculous and 
traumatic must be eliminated. 
Prognosis is guardedly favorable. Complications 
are very common. Recurrence and a crippled 
heart are to be feared. Occasionally the disease 
becomes subacute, all the symptoms becoming 
less prominent but more prolonged. Rarely it 
may become chronic. The subacute type may 
exist independently of any previous acute attack 
and is markedly resistant to treatment. 
Treatment. The parts must be placed at abso- 
lute rest, and the patient should lie between 
blankets. It is well to envelop the affected joint 
in soft wool or flannel. 
The diet should be composed of light broths, 
soups, beef-juice, milk, while there is fever; tea 
and coffee should be restricted to the minimum; 
vegetables and fruits of all kinds may be allowed 
with each meal. 
The hyperpyrexia should be constantly watched, 
and is best controlled by the cold bath or cold 
packs. The remedy which seems to be most cura- 
tive is some pharmaceutic preparation of salicylic 
acid, such as sodium salicylate: 
1$. Sodium salicylate, ( , ^ ... 
Aromatic elixir, /ea ' ° 
Water, add enough to make, § iij. 
One teaspoonful every 4 hours. 
If not well borne by stomach, the salicylates 
may be given by rectal injection of 20 to 40 grains. 
The bowels should be evacuated with fractional 
doses of calomel-1/4 grain may be given every 
hour until 6 doses have been taken-followed by 
1/2 ounce of Rochelle salt. Rochelle salt (1/2 
ounce) may be given every 2 days to keep the 
bowels open. 
The function of the kidneys should be carefully 
considered, and diuretics are distinctly indicated. 
1$. Lithium citrate, 3 jss 
Sweet spirit of niter, 3 v 
Solution of potassium citrate, 3 ij 
Simple elixir, 3 iv 
Water, add enough to make § iv. 
Two teaspoonfuls every 3 or 4 hours. RHEUMATISM, CHRONIC ARTICULAR 
RHEUMATISM, CHRONIC ARTICULAR 
1$. Potassium citrate, 3 iij 
Peppermint water, 3 j 
Water, add enough to make 3 iv. 
Two teaspoonfuls every 3 or 4 hours. 
Conjointly with the salicylates and alkalies, 
phenacetin may be used for the pain. Sometimes 
morphin may be necessary. 
Aspirin (g. v.) in doses of 5 to 15 grains has been 
proved to be a most efficient substitute for the 
older salicylates, as it has the advantage of not 
producing the unpleasant effects of the latter. 
A healthy action of the skin may be preserved 
by the use of flannel bedding and hot drinks, 
such as lemonade, hot beef-juice, and soups. 
Local Treatment.-A piece of flannel may be 
dipped in a mixture of lead-water and laudanum, 
applied to the affected part, and the whole envel- 
oped in wool or flannel and kept at rest. 
I). Tincture of opium, 3 iv 
Solution of lead subacetate, 3 iijss. 
One tablespoonful to a pint of water. 
3. Belladonna liniment, 3 iv 
Soap liniment, add enough 
to make 3 iij. 
Apply on flannel cloth once daily. 
Either of these local applications may be covered 
with oiled silk. A liniment containing salicylic 
acid is often very efficacious. Oil of gaultheria in 
olive oil (1:2) is excellent for local application. 
Should endocarditis supervene, successive blis- 
ters should be applied over the heart. An ice- 
bag over this area often relieves pain, lowers the 
temperature, and lessens the frequency of the 
heart-beat. 
As soon as the patient is able to be out of bed, 
massage and electricity applied to the joints are 
valuable, and tonics are necessary: 
1$. Strychnin sulphate, gr. j 
Quinin sulphate, 5 ij 
Mass of carbonate of iron, 3 jss. 
Make into 50 pills. One pill after each 
meal. 
1$. Elixir of phosphates of iron, 
quinin, and strychnin, 3 iv. 
Teaspoonful after each meal. 
RHEUMATISM, CHRONIC ARTICULAR.-A 
chronic inflammation of the soft parts of the 
joint, not due to trauma, or tuberculosis or septic 
infection. 
Etiology.-Same as acute, except that it occurs 
usually late in life and especially among the work- 
ing-class. Though as a rule appearing independ- 
ently, it may be a sequel to the subacute form or it 
may be followed by an acute or subacute attack. 
Present research is pointing to microbic origin. 
Pathology.-Similar to the acute but more pro- 
nounced. The capsule, tendons, and their sheaths 
are thickened and cause increase in size of the 
joint. Neuritis and muscular atrophy may super- 
vene about the joint. Ankylosis may occur. 
Symptoms.-The main symptoms are pain 
increased by movement and stiffness diminished 
by exercise. These are augmented by cold and 
damp weather. Tenderness and slight swelling 
may be found. Later ankylosis may occur. 
Fibrous changes of the heart muscle and valves 
are frequent. 
Prognosis.-While life is not shortened, the 
disease generally progresses. 
Treatment is mainly preventive. If subject to 
exposure, the patient should select an occupation 
which is less liable to increase the danger of an 
attack. Nutrition should be preserved by good 
food. As long as the condition of the patient 
permits, out-door exercise should be insisted upon. 
Tonics, such as iron, strychnin, cod-liver oil, ar- 
senic, should be administered. The bowels should 
be kept open with salines or laxatives, such as- 
1$. Fluidextract of cascara, 
Glycerin, 
each, 5 j. 
Or a pill containing aloin (1 grain), strychnin (1/60 
grain), and belladonna (1/8 grain) may be given. 
Should indigestion be present, lactopepsin (10 
grains) may be given after meals. 
I|. Pepsin, 
Dilute hydrochloric 
acid, 
each, 5 ij 
Compound tincture of gentian, 5 j 
Elixir of curacoa, 5 iv 
Water, add enough to make 5 iij. 
One teaspoonful after meals. 
Any of the diuretics mentioned for the acute 
form may be given if the urine becomes high-color- 
ed or scanty. 
Hot baths at night may be taken two or three 
times a week, and followed by thorough massage. 
Massage aids in breaking up the old adhesions and 
helps to restore the normal circulation. Vibratory 
massage may be beneficial. It is well to keep the 
affected joints wrapped up in flannel. lodin or 
blisters may be useful. Sometimes an ointment of 
ichthyol, mercury and belladonna wall prove valu- 
able. Chloral-camphor rubbed in well is effective. 
Scotch douches and moist compresses (hot and 
cold) may aid in the treatment. For great pain 
the actual cautery may be tried. The galvanic 
current may also be used for a period of 20 minutes 
3 times a week. The hot dry air treatment is 
effective in some cases. Great relief may follow 
the application of the high frequency current. Of 
internal remedies not one has been found to be of 
any distinct advantage. Sometimes an acute 
exacerbation may be controlled by salicylates. 
Potassium iodid (10 grains) may be given after 
meals for periods of 10 days or 2 weeks. Guaiac 
has been recommended; it should be given in the 
form of troches. The following prescription is 
commended: 
I|. Guaiac, 3 iij 
Oil of lemon, rq vj 
Oil of cloves, rq ij 
Sugar, 3 j 
Acacia, 5 ss 
Confection of rose, a sufficient quantity. 
Divide into 30 troches. One after each meal. 
See also Joints (Diseases). RHEUMATISM, INFANTILE 
RHEUMATISM, MUSCULAR 
RHEUMATISM, INFANTILE.-It should be re- 
membered that articular symptoms are relatively 
less prominent in children than in adults. The 
same is true of the profuse acid sweating so 
frequent with the adult. On the other hand, 
wandering rheumatic pains-the so called "grow- 
ing pains"-and rheumatic tonsillitis are among 
the more frequent symptoms of rheumatism in 
children. Pain, fever, swelling of the joints, and 
heart symptoms occur, of course, in typical 
cases of rheumatism, but of these the heart symp- 
toms are chiefly to be dreaded. Pain is quite 
likely to be slight and more of the nature of tender- 
ness and disinclination to move rather than sharp 
pain, and hence is often mistaken for a sprain. 
Fever, as a rule, is neither high nor long-continued, 
so that the heart symptoms are often the first to 
attract the attention of the parents. It is not 
always easy to decide whether we have to do with 
endocarditis, pericarditis, or both combined; but 
while it will be found that both are attended with 
restlessness, labored breathing, and elevated tem- 
perature, we expect to find a mitral murmur in 
endocarditis, systolic, and near the apex (ulcera- 
tive endocarditis is attended by fever and chills). 
Pericarditis usually is more painful than endo- 
carditis, generally gives friction sounds, with the 
cardiac sounds more distinctly at the base than at 
the apex. 
Diagnosis.-It is by no means always easy to 
make a positive diagnosis of rheumatism in a child 
unless there is coincident heart trouble. A rheu- 
matic family history, recurrent tonsillitis, or chorea, 
may give us valuable hints as to the attack, but 
antirheumatic remedies are often the best means 
of differentiation in doubtful cases. 
Treatment.-It is of first importance that the 
child should be clad in a flannel night-gown, put 
to bed, and kept under blankets until pain and 
tenderness have disappeared. If the joints are 
swollen and tender, they should be wrapped in 
cotton batting after rubbing with liniment; one of 
efficiency is the following: 
of the neck, the shoulders, the arms, the inter- 
costal muscles, the back, the thighs, and the calves 
of the legs. 
Etiology and Pathology.-Exposure to cold, and 
especially to drafts of cool air, as from an open door 
or window, are the most frequent causes. The 
acute form, at least, does not wander, but persists 
in the muscles primarily attacked until relieved. 
Its true nature is unknown, and whether it is an 
affection of the muscular substance or of the inter- 
muscular connective tissue or of the minute branches 
of sensory nerves distributed throughout the mus- 
cles is also unknown. Certain forms of muscular 
rheumatism, especially of the back, are ascribed 
to gout. An infectious origin has been suggested. 
It is sometimes associated with articular rheuma- 
tism, but has probably a different etiology, though 
similar exciting causes operate to produce it. 
Similar pain often succeeds muscular strain, but 
it is doubtful if this should be called muscular 
rheumatism. The division of muscular rheuma- 
tism into acute and chronic is based upon the 
duration of the pain and disposition to recurrence. 
The term chronic is justified for those forms which 
recur with changes in the weather, and are either 
excited or relieved by them. It, too, is less local- 
ized than the acute. On the other hand, it is not 
inaptly at times called wandering. It is more 
frequent in men than in women, because the 
former are more exposed to its cause. 
Symptoms.-The only invariable symptom is 
pain, aggravated by motion or pressure. Some- 
times there is swelling. It is usually rather sud- 
den in its onset, requiring at most but a few hours, 
and often less, to develop it. It is never accom- 
panied by marked constitutional disturbance. The 
pulse may be somewhat accelerated and the tem- 
perature approach 100° F., but more often there 
is no fever at all. 
Muscular rheumatism is specially named accord- 
ing as it involves certain muscles. Thus, lumbago 
is a painful affection of the lumbar muscles and 
their tendinous attachments. The attacks come 
on under the conditions already named, but some- 
times suddenly without discoverable cause. 
Stiff neck, or torticollis, is an affection of the side 
and back of the neck, forcing the patient to hold 
his head to one side as the situation of least dis- 
comfort, and when he desires to turn his head, he 
is forced to turn the whole body. Sometimes it 
becomes chronic and is rather difficult to cure. It 
is more frequently met with in children and young 
adults. Omalgia is a similar condition of the mus- 
cles of the shoulder and upper arm, making mo- 
tion exquisitely painful. Ankylosis of the shoul- 
der-joint may be caused by delayed motion. 
Pleurodynia affects the intercostal muscles and 
makes breathing and coughing very painful, while 
a deep breath'becomes impossible, and sneezing an 
agony. The pectoral and serratus muscles may 
also be involved when the pain is felt in their 
locality. It is more frequent on the left side. 
The duration of the acute form is brief, seldom 
lasting more than a few days, though there may 
be a tendency to relapse. The chronic forms are 
indefinite in duration. 
3. Oil of gaultheria, 
Spirit of chloroform, 
each, o ss 
Soap liniment, 5 iij. 
Of internal remedies the salicylates justly hold 
the first place, though they sometimes produce 
hebetude and depression of the heart's action with- 
out any appreciable effect in warding off heart 
complications. Aspirin is usually preferable to 
sodium salicylate because of its having no by- 
effects. Da Costa prefers the bicarbonate of 
sodium in mint-water until the urine becomes 
alkaline. Quinin sometimes acts well when all 
the usual remedies have failed, and opiates, especi- 
ally codein, are permissible for pain. lodids are the 
chief reliance in pericarditis and endocarditis. 
Absolute rest must be insisted upon. 
RHEUMATISM, MUSCULAR (Rheumatic Myos- 
itis, Myalgia).-A painful condition of voluntary 
muscles and their aponeurotic coverings, especi- 
ally aggravated by motion and pressure. It 
affects especially large muscles, such as those RHEUMATOID ARTHRITIS 
RHINITIS, ACUTE 
Diagnosis.-This is easy for the coarser acute 
forms of omalgia, stiff neck, and lumbago. Muscu- 
lar rheumatism may, however, be confounded with 
neuritis and neuralgia. In muscular rheumatism 
the pain is more diffuse; in neuritis there are pain 
and tenderness, more localized and along the course 
of large nerve-trunks. Muscular rheumatism 
and neuritis are distinctly worse on motion; 
neuralgia is less so. Rheumatism is commonly 
relieved by the warmth of the bed; neuritis may 
be aggravated; while neuralgia is indifferent, 
though increasd by cold winds. Pleurodynia is 
sometimes difficult to distinguish from intercostal 
neuralgia, but attention to the points named will 
prevent mistakes. Neuritis of the brachial nerve- 
trunks resembles omalgia, but the former is 
early followed by atrophy, while muscular rheu- 
matism is not. From pleurisy, pleurodynia is 
easily distinguished by the absence of fever and 
of physical signs. The lancinating pains of loco- 
motor ataxia and the pains of incipient disease 
of the vertebrae resemble at first those of lumbago, 
but the special symptoms of these diseases are soon 
superadded. 
Treatment.-The acute form of muscular 
rheumatism is occasionally amenable to treatment 
by the salicylates and salicin. Salipyrin and 
aspirin have been used with great benefit. The 
group of muscles treated must be placed at ab- 
solute rest, and in the case of the thorax this is best 
accomplished by strapping the side with adhesive 
plaster. Rest may, however, be overdone; and 
in the case of muscles like those of the shoulder, 
atrophy may result from too prolonged rest. 
Another measure of great value is dry heat, 
applied by means of a hot-water bag covered with 
flannel, or by a warm flat-iron. A flannel cloth 
should be interposed. With these measures 
massage may be associated. Of less permanent 
utility are hot poultices, although they allay pain 
at least. The same effect is accomplished by 
moist hot air or vapor (steam) baths, which in 
special establishments can be localized. 
The chronic form is also treated by massage, 
passive motion, and electricity, either the induced 
or direct current. Counterirritation by liniments, 
such as those made with choloroform, ammonium 
hydrate, or turpentine, have long enjoyed a reputa- 
tion, but at the present day it is beginning to be 
questioned as to whether, after all, it is not the 
friction rather than the liminent itself that pro- 
duces the good effect. Acupuncture, consisting of 
the puncture by needles deeply thrust into the skin, 
is a measure that has some advocates, especially 
in the treatment of lumbago. Hydrotherapy is 
more likely to be useful, and here the warm or 
cold pack is the better method of application. Dry 
cupping is also often of service. General treatment 
should not be neglected; cod-liver oil, iron, strych- 
nin, quinin, and good food should be given 
when the patient is run down (Tyson). 
Vibratory massage or the hot dry air treat- 
ment may be beneficial. The high-frequency 
current has given excellent results. 
RHEUMATOID ARTHRITIS.-See Joints (Dis- 
eases). 
RHINITIS, ACUTE (Coryza). Varieties.-(1) 
Simple rhinitis; (2) specific rhinitis. 
Etiology. Simple Rhinitis.-(1) Exposure to the 
cold and wet; (2) inhalation of dust or chemicals; 
(3) predisposing causes, such as rheumatic dia- 
thesis, tuberculosis, and asthma. 
Specific rhinitis is due to diphtheria and scarlet 
fever. 
Pathology.-There is vasomotor dilatation with 
engorgement of the blood-vessels in the mucous 
membrane, the latter being covered by amucoserous 
exudation. The membrane is red and swollen. 
Symptoms.-The symptoms are generally usher- 
ed in with a severe spell of sneezing, dryness of 
nasal chambers, hoarseness, headache, and a feeling 
of chilliness. Large quantities of mucoserous 
material may be expelled after a few hours, and 
the choanae may be entirely occluded by thick, 
tenacious material. See Nose (Examination). 
Often the Eustachian tube becomes clogged up. 
causing a ringing or buzzing noise, and temporary 
deafness may be set up. 
Prognosis is favorable for simple acute rhinitis. 
General Treatment.-Probably the patient would 
always be cured of his cold quicker if he could 
be induced to go to bed, or, if not, to remain in a 
room kept at the same temperature during the day. 
Coexisting with the congestion of the nasal mu- 
cous membrane there is very likely a partial cessa- 
tion in the activity of the emunctories of the 
body; therefore it is most important to use 
means to promote their activity. 
The bowels may be moved by means of frac- 
tional doses (1/6 grain) of calomel, salines, 
Seidlitz powders, or solution of magnesium citrate. 
To limit the nasal secretion by contracting the 
capillaries, Lennox Browne recommends: 
I|. Tincture of bella 
donna, 
Tincture of opium, 
each, xx 
Camphor water, o iv. 
Two tablespoonfuls 2 hours after meals. 
Probably that which may give quickest relief 
is a hot foot-bath taken at bedtime. The water 
should be as hot as can be borne, and the imbs 
should be bathed as high up as the knees. Fifteen 
or 20 minutes may be well spent in applying this 
measure of relief, and the process again repeated 
during the night, and for several consecutive 
nights if necessary. A small amount of powdered 
mustard may be added to the bath. Hot drinks, 
such as lemonade containing a small amount of 
brandy, may be given after the foot-bath to promote 
diaphoresis. Quinin (4 to 6 grains) and salol (2 to 4 
grains) aid in restoring warmth to the body, 
and may be used every 3 or 4 hours. Dover's 
powder (7 grains) is recommended by many good 
writers. 
Local treatment in some cases does good, and in 
others harm. In the acute stage, if a spray is 
used at all, only the gentlest force is permissible. 
If the anterior naris is entirely occluded, it 
may be relieved by applying a few drops of a 
solution of cocain (4 percent) on a pledget of cotton, 
and the nostril can be subsequently cleansed by RHINITIS, CHRONIC 
means of some form of douche containing an alkal- 
ine solution, such as that advised by Carl Seiler 
-cold cream (1 ounce) or liquid vaselin containing 
menthol (4 grains)-may be brushed over the 
nares to relieve congestion. See also Coryza. 
Treatment of Specific Rhinitis.-See Diphtheria, 
Scarlet Fever. 
RHINITIS, CHRONIC (Chronic Nasal Catarrh). 
-Etiology is the same as that of acute rhinitis; 
and it may result from an acute attack. 
Pathology. Hypertrophic Form.-Cellular infil- 
tration causes an overgrowth of tissue, giving rise 
to a spongy condition. The process most often 
affects the middle and inferior turbinated bones, 
and may be localized. In many cases deflection 
of the septum has been found, and nasal spurs 
are common. The surface is covered with 
a thick tenacious mucus. 
Atrophic Form.-Instead of a hypertrophic con- 
dition there may be atrophy of the mucous mem- 
brane often involving the bone and giving rise to 
enlargement of the nasal chamber. On the sur- 
face of the mucous membrane a greenish or yellow- 
ish and very offensive secretion is usually found, 
containing various microorganisms. Greenish or 
mottled crusts may be found scattered over the 
surface of the nares. This form is also spoken of 
as ozena. See Nose (Caries). 
Symptoms.-There is generally a feeling of stuffi- 
ness or inability to breathe through the nostrils, 
especially noticeable in the morning; a frequent 
desire to clear the throat; the voice is harsh, in- 
distinct, or nasal in character; the breath-sounds 
seem forcible or wheezing; the hearing and taste 
may become impaired, and from the occlusion of 
the nares the habit of mouth-breathing may be 
established. 
Often only one nasal chamber is affected, and 
the patient may complain of being able to breathe 
only through one or the other side of the nose. A 
physical examination reveals its character. 
In the atrophic form headache may be more com- 
mon, and the secretion, instead of being mucoser- 
ous, has a greenish or purulent cast, often con- 
taining greenish crusts. 
Complications -Deafness is common. 
Diagnosis is based on anterior and posterior 
rhinoscopy. 
Prognosis is guardedly favorable. The condition 
is prone to reappear. 
General Treatment.-While the local treatment 
of the disease is probably of most importance, the 
general condition of the patient must never be 
neglected. Careful inquiry should be made regard- 
ing the habits, such as inveterate use of tobacco, 
overloading the stomach, bathing at unseasonable 
hours or in water too cold, and also the condition 
of the digestion and state of the bowels. 
If the general system is below par, a tonic- 
such as the elixir of the phosphates of iron, quinin, 
and strychnin (1 dram)-is advisable, taken after 
meals. 
The constipation should be treated by appro- 
priate remedies. See Constipation. 
Local Treatment.-The nasal chambers should 
be throughly cleansed and kept in as healthful a 
RHINITIS, CHRONIC 
condition as possible by the use of alkaline anti- 
septic sprays or douches. A good cleansing fluid 
is composed of listerine (1 part) and water (2 
parts). 
The fluid for the spray may also be made by 
dissolving a tablet, according to the formulas of 
Dobell or Seiler, in about 2 ounces of water, and 
used by means of the compressed-air apparatus 
(preferably) or the glass hand-atomizer. Both the 
anterior and posterior nares are cleared of mucus 
and dust by this method. The small glass nasal 
douche seems to be effective in mild cases. 
If the compressed-air apparatus is used, much 
care should be exercised not to use too great a 
force, as damage to the sensitive membrane may 
ensue. Usually, a pressure of from 5 to 7 pounds 
is sufficient. The nasal chambers may be cleansed 
in this manner 2 or 3 times a week. 
Before using the liquids during cold weather it is 
best to slightly warm them. Carbolic acid should 
be used with caution about the nasal chamber, as 
it has been known to produce anosmia. 
Subsequent to the cleansing process the follow- 
ing solution feels refreshing: 
3. Eucalyptol, 
Menthol, 
each, gr. j 
Liquid vaselin, 5 j. 
Use as a spray. 
A drop or two of the compound tincture of 
benzoin may then be sprayed over the parts to 
advantage. 
Here a word of warning against the indiscrimin- 
ate use of the nasal douche is appropriate. In 
cases of nasal hypersecretion due to other causes 
than inflammation of the nasal and retronasal 
mucous membrane, sinusitis, deviation of the sep- 
tum, some new growth in the nasal cavity, etc., it 
is still common practice to have recourse to the 
nasal douche. In the majority of such cases this 
is useless, and it may seriously injure the epithe- 
lium of the nasal mucous membrane. In numer- 
ous cases the power of smell was lost in this way, 
and experiment has shown that no active anti- 
septic solution is free from danger to the sense of 
smell. The nasal douche is, also, frequently the 
cause of distressing headaches, probably accounted 
for by fluid passing into the sinuses. One of the 
gravest dangers is that water may reach the mid- 
dle ear through the Eustachian tube and cause 
suppurative otitis media. 
Sprays or douches keep the parts clean but they 
do not altogether relieve the hypertrophy. This 
condition may often be relieved by a partial de- 
struction of the tissue by means of the galvano- 
cautery or chromic acid. 
Before these caustics are applied the parts are 
thoroughly anesthetized by means of a solution of 
cocain (5 to 10 percent). The cautery point is 
then plunged into the hypertrophied tissue in a 
direction parallel with the inferior border of the 
bone. In mild cases this operation, repeated 2 
or 3 times, suffices. In the more chronic forms 
linear superficial cauterizations may also be made. 
At least a week should elapse from the time of 
one application to the next. RHINOPHYMA 
RIBS, FRACTURE 
Hypertrophies on the posterior portion of the 
turbinated bodies are best removed with the knife, 
saw, or suture, as, being in close proximity to the 
Eutachian tube, the cicatrix formed by cautery 
might produce harm. There are many operations 
for straightening septal deviations. The applica- 
tion of chromic acid to hypertrophies has been 
advised by a few specialists with good results. The 
parts are anesthetized with a solution of cocain 
(10 percent), and the acid is applied by means of a 
metal probe. Its use is not altogether free from dan- 
ger of poisoning. See Nose (Caries, Deformities). 
RHINOPHYMA.-See Acne Rosacea. 
RHINOPLASTY.-See Nose (Deformities). 
RHINOSCOPY.-See Nose (Examination). 
RHUBARB (Rheum).-The dried rhizome of R. 
officinale, R. palmatum, or other species of Rheum. 
It contains three closely related anthracene 
derivatives, chrysophan, yielding chrysophanic 
acid, emodin, and rhein, which are the cathartic 
principles; also several bitter resins, a variety of 
tannic acid, calcium oxalate, starch, sugar, pectin, 
and other plant constituents. The species of rhu- 
barb cultivated in the United States are devoid 
of cathartic power, but their leaf-stalks are used 
as a fruit. Dose of the powdered root, as a stom- 
achic 1 to 5 grains, as a purgative 10 to 30 grains. 
Rhubarb is highly esteemed as a cathartic for 
children on account of the mildness of its action. 
The tonic and astringent action following its ca- 
tharsis makes it a valuable agent in diarrheas due 
to the presence of irritating matter in the bowel, 
and to correct atonic indigestion accompanied by 
diarrhea. For hemorrhoids with constipation its 
gentle action makes it peculiarly suitable, its 
astringent after-effect being entirely overcome by 
from 2- to 4-dram doses of olive oil nightly. It 
may be combined with a mercurial or with sodium 
bicarbonate. In small doses the tincture is a very 
efficient stomachic tonic, improving appetite, 
increasing the flow of the gastric juice, assisting 
digestion, and promoting the action of the liver 
without producing any cathartic results. The 
preparations most in use for children are the aro- 
matic syrup and the mistura rhei et sod®. 
Incompatible with rhubarb preparations are: 
Mineral acids, catechu infusion, cinchona infusion, 
galls infusion, lead acetate, lime-water, mercuric 
chlorid, silver nitrate, tartar emetic, zinc sulphate. 
Preparations.-Extractum R. Dose, 1 to 10 
grains. Fluidextractum R. Dose, 10 to 30 grains. 
Pilulae R. Compositae, each pill contains of rhubarb 
about 2 grains, aloes 1 1/2, myrrh 1, oil of pepper- 
mint 1/10 grain. Dose, 1 to 5 pills. Tinctura R., 
has of rhubarb 20, cardamom 4, glycerin 10, alco- 
hol and water to 100. Dose, 1/2 to 3 drams. 
Tinctura R. Aromatica, has of rhubarb 20, cinna- 
mon 4, cloves 4, nutmeg 2, glycerin 10, alcohol and 
water to 100 Dose, 10 to 60 minims. Syrupus 
R., has of the fluidextract 10, spirit of cinnamon 
0.4, potassium carbonate 1, glycerin 5, water 5, 
syrup to 100. Dose, for an infant, 1 dram; for 
older children, 2 to 4 drams. Syrupus R. Aro- 
maticus, has of the aromatic tincture 15, syrup 
85. Dose, as the syrup. Pulvis R. Compositus, 
has of rhubarb 25, magnesia 65, ginger 10. Dose, 
a teaspoonful. Mistura R. et Sodae, has of sodium 
bicarbonate 3 1/2, fluidextract of rhubarb 11/2, 
fluidextract of ipecac 1/3, glycerin 35, spirit of 
peppermint 3 1/2, water to 100. Dose, 1/2 to 4 
drams. 
In summer diarrhea of children: 
3- Aromatic syrup oi rhubarb, 5 vj 
Sodium bicarbonate, 5 ij 
Deodorated tincture of opium, np xxxvj 
Peppermint water, add 
enough to make § iij. 
To a child of from 4 to 6 years give a teaspoon- 
ful every 3 hours. 
RHUS GLABRA (Smooth Sumach).-The dried 
fruit of R. Glabra. The leaves and bark have an 
astringent and bitter taste, and are also used 
medicinally. It contains tannin, coloring matter, 
also potassium and calcium malates. 
Fluidextractum Rhois Glabrae. Dose, 5 to 30 
minims. Sumach-berries form a useful acidulous 
and astringent drink or gargle in catarrhal phar- 
yngitis, stomatitis, and aphthae. An infusion 
(one ounce to the pint) or the official fluidextract 
may be used as a wash and dressing for ulcers and 
wounds. Internally the berries are useful rem- 
edies for mild catarrhal affections of the stomach 
and bowels. 
RHUS TOXICODENDRON.-See Ivy Poisoning. 
RIB, CERVICAL.-See Cervical Rib. 
RIBS, FRACTURE.-This is a most frequent 
injury, occurring more often about the fifth to the 
eighth ribs, in middle-aged males, and in old per- 
sons. Direct violence usually produces fractures 
on only one side of the body, while indirect vio- 
lence affects one or both sides or breaks one rib in 
several places. Fractures may be produced by 
muscular action, as in coughing and sneezing. 
They are seldom compound, save from gun-shot 
injury. Fractures of the ribs may be complicated 
by: An external wound; a wound of the pleura 
and lung, or pericardium and heart; laceration of 
a blood-vessel, as an intercostal artery; penetra- 
tion of the diaphragm; and more rarely by per- 
foration of the peritoneum, and wound of the liver 
or spleen. Hence they may be followed by emphy- 
sema, pneumothorax, hemothorax, hemoptysis, 
hemopericardium, and later by pleurisy, pneu- 
monia, pericarditis, or peritonitis. 
Treatment.-The object of treatment is to so 
immobilize the fractured rib as to put it in the 
most favorable state for repair. The erect pos- 
ture is better than the prone. Displacement out- 
ward is corrected by direct pressure, while dis- 
placement inward is usually rectified by ordinary 
breathing or deep breathing brought about by 
anesthesia. As a temporary expedient only the 
forcibly applied broad rib-roller may be used. 
Broad bands (2 inches wide) of adhesive strips, 
extending from the spine to the sternum, and 
overlapping freely, applied with the arms held 
over the head while forced expiration is employed, 
and being put on from 6 or 7 inches below' the seat 
of fracture successively upward, are commonly 
used. An inelastic spiral or figure-of-eight ban- 
dage may be put over the strips. The strips should RIBS, RESECTION 
RICKETS 
be worn for 3 or 4 weeks; fresh pieces being reap- 
plied about once a week, the chest being rubbed 
with soap liniment, dried, and excoriations treated, 
as by zinc ointment. Cold, damp, and drafts are 
especially to be avoided; the diet should be non- 
stimulating, and cough should be checked by 
opiates and expectorants. In those over 60 years 
of age stimulating expectorants are called for, or a 
steam-tent may be used several times daily. 
Confinement in bed is necessary when fracture 
of the rib is complicated with dangerous visceral 
injury. The circulation is to be reduced, the 
patient treated with adhesive strips as before 
described, put to bed, and diaphoretics and expec- 
torants-such as a mixture of squill, ipecacuanha, 
ammonium acetate, chloroform, and opium- 
employed. When there is emphysema, it usually 
disappears of itself, but it may be necessary to 
open the cellular tissue and employ pressure under 
antiseptic precautions. If a sudden attack of 
dyspnea comes on, it is then advisable to bleed the 
patient almost to syncope. Pleurisy ensuing from 
fracture of the rib is mostly local, and is to be 
treated the same as ordinary inflammations of 
such membranes. So severe may be the visceral 
injury, or the patient's state, that it may be advisa- 
ble to resect a rib, and on investigation treat such 
complication as may be found, and drain. Hemor- 
rhage from an internal bleeding point indicates 
the resection of a rib, finding the bleeding point, 
and ligation thereof. See Pleurisy. 
When the costal cartilages are fractured, an 
attempt should be made to reduce the displace- 
ment: if forward, by drawing back the shoulders; 
or if backward, by employing deep inspiration. 
A truss may be employed over the projection 
caused by a broken cartilage for a day or two to 
reduce the deformity. The case should be dressed 
and treated the same as a fractured rib-removing 
the dressings in 4 weeks. 
RIBS, RESECTION.-See Pleurisy (Treat- 
ment). 
RICINUS.-See Castor Oil. 
RICKETS (Rachitis).-A disease characterized 
by nutritional changes, deformities of the bones, 
weakness of the muscles and ligaments, and vari- 
ous nervous disorders. It occurs especially 
between the ages of 6 months and 2 years. See 
Bone (Diseases). 
Etiology.-The principal cause of rickets is 
improper feeding. Unhygienic surroundings, he- 
reditary weakness, and feebleness of the digestive 
powers are also important factors in producing 
this disease. Breast-fed babies are seldom affect- 
ed ; but when the mother's milk is scanty and poor, 
as is likely to be the case when the child is weaned 
late, rickets may occur. Those suffer most fre- 
quently who are artificially fed, who receive their 
nourishment irregularly, and are fed on improper 
substances, as starches, condensed milk, cow's 
milk boiled, unmodified, or of an inferior quality, 
and the various proprietary foods. As the class 
that most often rear their children in this manner 
are also those whose hygienic surroundings are 
of the worst, naturally it is among them that 
rickets is most common. 
Pathology.-Bronchitis is very common. The 
stomach and intestines are often dilated; the liver 
may be enlarged, and enlargement of the spleen is 
frequently present. The only characteristic le- 
sions of rickets, however, are those found in the 
bones. There are an increased production of 
cartilage at the epiphysis and excessive cell growth 
beneath the periosteum, while the process of 
ossification goes on very slowly or is entirely 
arrested, which accounts for the unnatural flexi- 
bility present in rachitic bones. Normally the 
bones contain about two-thirds inorganic and one- 
third organic matter; but in rickets there is a 
marked deficiency in the proportion of lime salts, 
and the proportions mentioned above may in 
severe cases be reversed-there being present 
twice as much organic as inorganic matter. 
There are also characteristic changes in the form 
of the bones, the principal ones being curvatures 
and enlargement of the epiphyses of the long bones, 
and thickening of the bones of the skull. 
Symptoms.-The early symptoms may be so 
mild as to be overlooked. In more severe cases 
there will be restless sleep, profuse sweating of the 
head, digestive and nervous disturbances, and 
perhaps slight fever. 
Bending of the ribs (the rachitic rosary), caused 
by nodules formed at the junction of the costal 
cartilages and the ribs, and enlargement of the 
wrist-joints are the earliest noticeable changes in 
the bones. Dentition in most cases is delayed or 
arrested, and the fontanels remain open. The 
appetite is capricious: constipation, which may 
alternate with diarrhea, is usually marked, and the 
abdomen is enlarged (often enormously) and 
tympanitic. 
Most rachitic patients are anemic, fat, and flabby, 
and they are very liable to suffer from inflam- 
mations of the mucous membranes, as gastro- 
intestinal catarrh, bronchitis, and pneumonia. 
Tenderness of the epiphyses and bones may be 
present, but is neither a constant nor reliable symp- 
tom, and when present to a marked degree sug- 
gests scorbutus rather than rickets. 
Nervous symptoms are frequent and important; 
the nerve-centers are in an unstable condition and 
discharge on the slightest provocation, giving rise 
to restlessness at night, to laryngismus stridulus, 
tetany, or general convulsions. 
The deformities most uniformly found as a 
result of rickets are flat feet, enlarged epiphyses, 
bow-legs or knock-knees, a malformed thorax 
(pigeon-breast), and a large square head.- In 
severe cases the spine may become deformed, and 
not infrequently there occur deformities of the 
pelvis. 
The course of rickets is chronic, the active 
symptoms continuing for a period of from 2 or 3 
to 18 or 20 months. The earliest symptoms of 
improvement are a diminution of the nervous 
symptoms, and of the head sweats, improvement 
in the anemia, and an increase in the muscular 
power. When improvement once begins, it 
usually goes steadily forward, relapses being 
exceedingly rare. 
Diagnosis.-The early symptoms mentioned- RICKETS 
sweating of the head, craniotabes, great restless- 
ness at night, and delayed dentition-when 
occurring together are diagnostic of rachitis, but 
in cases when these symptoms are obscure, the 
exact nature of the affection may be doubtful 
before the bones show the characteristic changes. 
Hereditary syphilis presents some symptoms 
which may be taken for rickets, but the lesions of 
the skin and mucous membrane and the difference 
in the character of the bone lesions are diagnostic. 
When there is enlargement of the long bones in 
syphilis, it is not confined to the epiphysis but 
involves the end of the diaphysis, and it often is 
accompanied by a condition that closely simulates 
a callus. There is a distinct tendency to fracture 
in syphilis rather than to the bending that is 
common in rickets. 
The diagnosis between rickets and scurvy is 
mentioned under the description of the latter 
disease. See Scurvy. 
Prognosis.-Many dangers attend rickets on 
account of the weakly state of the child. He is 
especially liable to bronchitis and bronchopneu- 
monia, which are particularly dangerous owing to 
the weakness of the ribs and the feebleness of the 
respiratory muscles. 
One of the effects of rickets is to stunt the 
child's growth as well as to leave him with deform- 
ities. The lowering of the health produced by 
rickets may last for many years, but in the major- 
ity of cases the symptoms and signs of this disease, 
if they come under treatment, disappear, and the 
child may grow up into a healthy adult. 
Treatment.-The treatment of rickets is chiefly 
dietetic and hygienic. When possible, the patient 
should be taken to live in the country, or better- 
as the salt air is especially beneficial-at the sea- 
shore. He should be kept in the open air as much 
as possible, guarding against bronchitis by keeping 
him well covered with a woolen blanket and by 
keeping his feet warm. The living room should be 
accessible to sunlight, and the child should be 
given a daily warm salt-bath, followed by an 
inunction of cod-liver oil. 
The food should be adapted to the child's age, 
and given in proper amounts and at regular in- 
tervals. See Infant Feeding. The sugar and 
starches should be reduced in the food, and the 
proprietary infant foods not given. Beef-juice 
should be added to the infant's diet. This is 
prepared by taking 1 pound of finely chopped 
round steak, 6 ounces of cold water, and a pinch 
of salt; place in a covered jar and stand on ice 
or in a cold place for 5 or 6 hours. This is now 
strained and all the juice squeezed out of the meat 
by placing it in coarse muslin and twisting it 
very hard. One teaspoonful of this may be given 
in the milk, or separately before taking the bottle, 
3 times a day to a child 6 months old, increasing 
the amount gradually to 4 to 6 tablespoonfuls 
daily at 11 or 12 months. From 10 to 18 months 
there should be added to the diet list eggs, scraped 
raw meat, orange-juice, and fresh fruits. 
Cod-liver oil should be given in all cases, and, 
except in hot summer weather, it is usually well 
tolerated. It is best given pure, the dose being from 
10 drops to a teaspoonful 3 times a day, according 
to the child's age and its capacity for digesting it. 
It may be combined as follows: 
RICKETS 
I|. Syrup of lactophos- 
phate of lime, 
Lime-water, 
each, 3 ij 
Cod-liver oil, 3 iv. 
From 1/2 to 2 teaspoonfuls 3 times a day. 
Or with phosphorus: 
3. Phosphorated oil, 3 ss 
Cod-liver oil, 3 vj. 
From 1/4 to 1 teaspoonful 3 or 4 times a day. 
For the anemia iron should be given. One or 
2 drops of the syrup of iodid of iron may be 
added to each dose in the above recipes, or it 
may be given as in one of the following: 
3. Syrup of iodid of iron, 3 j to ij 
Simple syrup, 3 iij. 
One-half of a teaspoonful in a little water 
3 times a day. 
1$. Citrate of iron and quinin, gr. x 
Cod-liver oil, 
Glycerin, 
each, 5 ij. 
One-half to 1 teaspoonful 3 times a day. 
For the relief of sweating when profuse give 
1/800 to 1/200 grain of atropin 3 or 4 times a day. 
When digestive disturbances are present, they 
should receive appropriate treatment. As a rule, 
such simple remedies as calomel and soda, in 
small doses, and essence of pepsin will meet the 
indications. 
Many of the deformities resulting from the 
softness of the bones may be prevented by pre- 
cautionary measures. The children must not be 
allowed to sit up before their vertebral column 
will support them. They must not be carried 
about in the erect posture nor on the same 
arm always, and they must be discouraged from 
walking before their limbs are sufficiently strength- 
ened. When there is craniotabes (thinning of 
the skull), the weight of the head must, as much 
as possible, be kept from falling upon that 
part of the skull. In very many cases slight 
deformities of the extremities are outgrown. 
Friction and intelligent manipulation of the ex- 
tremities will do much to strengthen the muscles 
and straighten the bones, but braces should be 
applied if the deformity does not yield to these 
measures. 
The deformity of the spine may be much bene- 
fited by postural treatment. The patient should 
lie upon a hard bed, no pillow should be allowed 
under the head; but in severe cases one should 
be placed beneath the back so that the spine is 
slightly raised. For a few minutes every day 
the child should be placed upon the face and 
the deformity overcome by raising the buttocks 
while pressure is made upon the spine. Fric- 
tion and massage should be employed to strengthen 
the muscles. In severe cases an apparatus, as a 
brace or plaster jacket^ should ibe worn a few 
hours every day. Little can be done toward cor- RIGGS'S DISEASE 
RINGWORM OF THE BODY 
reeling deformed bones by apparatus after the 
child is 2 1/2 years old, as the bones have then 
become hardened. After this time surgical treat- 
ment is the only means of cure. 
RIGGS'S DISEASE.-See Pyorrhce a Alveolaris. 
RIGOR.-The phenomena-all referable to the 
central nervous system-that constitute a rigor 
frequently portend serious illness. The attack 
frequently shakes every muscle, the teeth chatter, 
the face twitches, eyelids and mouth-corners 
irregularly move or twitch, temperature often 
rises, and the sensation of intense cold ensues. 
Besides other motor symptoms, disturbances of 
function occur. A rigor is sometimes produced 
by traumatic influence, as after sudden dilatation 
of the urethra by a catheter; but we are by no 
means enlightened as to the pathologic state of the 
central nervous system that produces the rigor 
preceding the onset of disease. 
A rigor occurring during the course of an illness, 
and not due to malaria, should suggest pus forma- 
tion or thrombosis. In malarial fever and in 
acute diseases, especially pneumonia and ery- 
sipelas, rigors are usually premonitory symptoms. 
The most usual treatment of a rigor has been that 
of stimulation and heat, through the use of brandy 
and hot water, hot bottles, and blankets. It 
is the disturbance of the heart that urges the 
necessity for treatment; and any drug that 
narcotizes the nerve-centers has a preventive 
effect on rigors. Chloroform will arrest a rigor, 
and morphin and quinin will prevent and arrest 
rigors due to catheterism. Practically, the 
administration of 1/4 to 1/3 grain of morphin 
hypodermically, with maintenance of external 
heat through hot-water bottles, hot blankets, or 
heated air, and the occasional use of hot alcoholic 
drinks, will suffice. See Chill. 
RIGOR MORTIS.-The muscular rigidity that 
occurs shortly after death, due to chemic changes 
resulting in the production of myosin. See 
Death (Signs). 
RINGWORM OF THE BEARD (Tinea Sycosis; 
Barbers' Itch).-A contagious, vegetable parasitic 
affection, attacking the hairs and hair follicles of 
the bearded region. 
Symptoms.-The disease begins with the appear- 
ance of small, rounded, scaly, reddish patches 
(tinea circinata). The hairs and their follicles 
soon become invaded, with the production of 
swelling and induration and the appearance 
of nodular or lumpy tumefactions. Numerous 
pustules mark the sites of the hair follicles. These 
soon rupture and give exit to a yellowish pus, 
which dries in the form of crusts. The hairs are 
dry and brittle, and either break off or fall out. 
The chin, neck, and submaxillary region are the 
regions most frequently affected. The upper lip 
is almost never attacked. Itching and burning 
are present in varying degrees. The disease, 
when untreated, persists indefinitely. Unless 
treatment is extremely thorough, relapses are 
liable to occur. 
Etiology.-The disease is due to the invasion of 
the hair follicles by the ectothrix variety of the 
trichophyton fungus. The affection is usually 
acquired in the barber shop. The disease, how- 
ever, is not infrequently contracted from horses 
and cattle. When acquired from such sources, it 
is apt to be more severe. 
Pathology.-Both the hair and the hair follicles 
contain the fungus. As in tinea tonsurans, the 
spores greatly predominate over the mycelium. 
Secondary inflammation of the' follicles and sur- 
rounding tissues, with swelling, infiltration, and 
suppuration, are present in well-marked cases. 
Diagnosis.-The chief affection to be differen- 
tiated is ordinary sycosis. 
Tinea Sycosis. 
1. A typical case shows 
large, lumpy, or 
nodular tumefac- 
tions. 
2. Hairs broken and 
easily extracted. 
Roots usually dry. 
3. Course rapid. Mark- 
ed changes from 
week to week. 
4. Upper lip almost 
never involved. 
5. Trichophyton fungus 
in hairs. 
Sycosis. 
1. A typical case shows 
small, discrete pus- 
tules pierced by 
hairs. 
2. Hairs firmly at- 
tached until free 
suppuration occurs. 
Roots often swollen 
with pus. 
3. Course slow. Little 
change from week 
to week. 
4. Upper lip frequently 
involved. 
5. Absence of fungus in 
hairs. 
Prognosis.-The disease is at times rebellious to 
treatment, although most cases get well in 1 or 2 
months. Relapses are common. 
Treatment.-The treatment consists of epilation 
and the use of parasiticide applications. Crusts 
should be softened with bland oils and then re- 
moved with soap and warm water, after which the 
part should be shaved. Shaving and epilation of 
the diseased hairs should then be practised upon 
alternate days. 
The following applications are all efficient: 
1$. Precipitated sulphur, 5 j 
Petrolatum, 3 j • 
Sodium thiosulphate, 3 j 
Water, 3 j. 
I). Mercuric chlorid, gr. j 
Water, 3 j. 
These should be applied 2 or 3 times a day. 
RINGWORM OF THE BODY (Tinea Circinata). 
-A contagious, vegetable parasitic disease, due to 
the trichophyton megalosporon, or large-spored 
fungus, or the microsporon audouini or small- 
spored fungus, and characterized by annular vesic- 
ulosquamous patches upon the body surface. Of 
the trichophyton there are two main varieties, the 
endothrix which causes the transitory forms of 
macules, and the ectothrix to which is due the 
severely inflammatory type of the disease. Ring- 
worm of the general surface or the bearded region 
is due generally to the ectothrix; that of the scalp 
is usually caused by the endothrix. In children, 
however, ringworm of the scalp is as a rule due to 
the microsporon though occasionally to the tricho- 
phyton. RINGWORM OF THE BODY 
RINGWORM OF THE SCALP 
Symptoms.-The disease begins as one or several 
rounded or irregular pea-sized, hyperemic, scaly 
patches. In a few days these assume a circular 
shape with minute papules or vesicles around the 
circumference. 
Peripheral spreading and central healing prog- 
ress hand in hand, so that the patches when fully 
developed are distinctly annular or ring-shaped. 
They are of a dull pinkish or reddish color, with 
slightly elevated borders, which exhibit a branny 
desquamation. Itching is usually slight. The 
face, neck, and backs of the hands are the most 
frequent seats. 
In tinea cruris (eczema marginatum, tinea tricho- 
phytina cruris) the clinical appearances are so * 
much modified as frequently to simulate an eczema 
intertrigo. The patches are large, diffuse, of a 
dull or brownish-red color, with a well-defined 
marginated, and at times slightly elevated, border. 
Outlying circinate patches are usually present. 
The eruption spreads with remarkable rapidity, 
successively involving the thighs, groins, genitals, 
mons veneris, and nates. Eczema is apt to com- 
plicate the affection. The itching is often severe, 
particularly at night. 
Tinea Trichophytina Unguium (Onychomycosis, 
Ringworm of the Nails).-Occasionally, the nails 
are invaded by the ringworm fungus. They be- 
come opaque, white, thickened, and soft or brittle. 
Two or three nails are usually affected. The disr 
ease runs a chronic course, and is refractory to 
treatment. 
Pathology.-The fungus is found in the epider- 
mis, particularly in the corneous layer. Myce- 
lium is abundant, spores scanty. The former con- 
sists of long, slender, sharply contoured, bifurcated, 
jointed threads. The spores are rounded, highly 
refractive bodies, varying from 1/1000 to 1/600 
inch in diameter. 
Diagnosis.-Tinea circinata may be distin- 
guished from eczema, psoriasis, and seborrhea by 
the superficial character of the lesions, their annu- 
lar configuration, the history, the course, and, 
finally and conclusively, by the microscopic 
examination. 
Method of Examining for the Fungus.-Epider- 
mic scales are scraped off with a knife and placed 
on a microscopic slide with a drop of caustic potash 
(20 to 40 percent). A cover-glass is then applied, 
with sufficient pressure to flatten out the scales. 
The fungus is best studied with an oil-immersion 
lens, although it can be seen with the dry system. 
Prognosis.-As a rule, the affection yields 
promptly to treatment. Tinea cruris is more 
rebellious than the ordinary form. 
Treatment.-The treatment consists in the use 
of parasiticide ointments and lotions. Mercury, 
sulphur, beta-naphthol, resorcin, tar, and chrys- 
arobin are all valuable. An efficient formula is: 
1$. Ammoniated mercury, gr. xx to xl 
Zinc oxid ointment, 3 j. 
Thiosulphate of sodium (1 dram to 1 ounce of 
water) and bichlorid of mercury (1 to 3 grains to 
1 ounce of water) are useful applications, especially 
in tinea cruris. 
RINGWORM OF THE SCALP (Tinea Tonsurans). 
-A contagious, vegetable, parasitic disease, charac- 
terized by circumscribed areas of partial baldness, 
with evidence of disease of the hairs. 
Symptoms.-The disease begins with small, 
rounded, reddened scaly patches, occurring upon 
any portion of the hairy scalp. Soon the follicles 
become invaded and circumscribed hair-fall results. 
Typical lesions consist of partially bald, discrete, 
rounded, coin-sized, slightly reddened patches 
covered with grayish scales. The follicles are 
prominent, producing a "goose-flesh" appearance. 
The hairs are lusterless, and consist of "broken 
or gnawed-off stumps." They lie loosely in the 
follicles and are easily extracted. 
In rare cases ringworm may affect the scalp 
diffusely, without the production of circumscribed 
patches (disseminated ringworm). 
The only subjective symptom is itching, which is 
usually of a mild character. The disease occurs 
almost exclusively in children. In adults it is so 
rare as to constitute a dermatologic curiosity. 
The course of the affection is extremely chronic. 
When cure results, full restoration of hair takes 
place. 
Tinea kerion is a highly inflammatory ringworm 
terminating in suppuration. The patches are 
reddish or yellowish, raised, edematous, and 
boggy; they are honeycombed with distended 
openings of hair follicles, through which exudes a 
yellowish pus. Burning, itching, tenderness, and 
pain are present in a variable degree. The sup- 
puration of a ringworm hastens its cure, but is apt 
to destroy the follicles and produce permanent 
baldness. 
Etiology.-The cause of the disease is the tri- 
chophyton fungus or the microsporon audouini. 
Ringworm is essentially a disease of childhood. 
The affection is communicated from one child to 
another by means of caps, brushes, combs, towels, 
etc. It may also be contracted from the lower 
animals, such as the cat, dog, horse, or ox. Tinea 
circinata in the adult may produce tinea tonsurans 
in the child, and vice versa. 
Pathology.-The fungus is found in the hair, the 
hair follicle, and the epidermis. In this form of 
the disease the spores are extremely abundant in 
the hair, producing under the microscope a fish-roe 
appearance. The mycelium is scanty or absent. 
The hair is prepared by immersion in liquor 
potassse, and is examined without staining. Only 
broken-off hairs are to be selected for examination. 
Diagnosis.-The characteristic features of tinea 
tonsurans are circumscribed patches of partial 
baldness, grayish scales, goose-flesh appearance, 
broken-off stumps of hair, and the presence of the 
fungus. 
These points will enable one to distinguish the 
disease from eczema, psoriasis, and seborrhea. 
The differential diagnosis from alopecia areata is 
here appended: 
Tinea Tonsurans. 
1. Slow and insidious 
onset. 
2. Patches are 
Alopecia Areata. 
1. Rapid onset. 
2. Patches are RINGWORM OF THE SCALP 
ROENTGEN RAYS 
Tinea Tonsurans. 
(a) Covered with 
"broken-off 
. stumps." 
(5) More or less red- 
dened. 
(c) Rough and scaly. 
(d) Follicles promi- 
nent; goose-flesh 
appearance. 
3. Trichophyton fungus 
present. 
4. Occurs almost exclu- 
sively in children. 
Alopecia Areata. 
(a) Totally devoid of 
hair. 
(5) Pale and whitish. 
(c) Smooth and soft. 
(d) Follicles con- 
tracted. 
3. Absence of fungus. 
4. Common in adoles- 
cence and in adults. 
ringworm: Towels, brushes, combs, caps, soap, 
and other articles used by a ringworm patient 
should never be used by any one else. Physicians 
should prohibit children affected with tinea 
tonsurans from attending school until they are 
entirely cured. It is a great hardship upon a child 
to enforce its absence from school for a year or 
more, but it is the only method of stamping out 
this affection. 
RISUS SARDONICUS.-A peculiar expression of 
the face, in which the features are distorted by 
spasm of the muscles so as to present the appear- 
ance of a painful grin or laugh. It is most usually 
observed in tetanus. After a full dose of strychnin 
(1/12 grain), among other symptoms, the face 
will take on an unmeaning smile, or risus sardoni- 
cus. The condition in itself is not to be treated, 
but its cause demands immediate removal. 
RITTER'S DISEASE.-See Dermatitis Exfoli- 
ativa Neonatorum. 
RODENT ULCER (Jacob's Ulcer; Cancroid 
Ulcer; Ulcus Exedens; Noli me Tangere).-A 
peculiar form of superficial epithelioma, almost 
invariably limited to the upper two-thirds of the 
face. It occurs in old age, and begins as a little 
nodule which ulcerates. The ulcer is round, oval, 
or irregular, with indurated everted edges and a 
smooth, glossy, pinkish surface; the discharge is 
slight, pain is absent, adjacent lymph glands are 
not involved, metastases do not occur, and the 
general health is unimpaired except in the later 
stages, death resulting from hemorrhage or from 
the local destruction of important organs. The 
disease progresses very slowly, sometimes lasting 
30 or 40 years, and occasionally cicatrizes in spots, 
the scars later breaking down. The ulcer ad- 
vances principally along the surface, although in 
the later stages it extends deeply and destroys 
everything in its path, including the bones. The 
disease may originate in any of the epidermal 
structures. See Epithelioma. 
ROENTGEN RAYS.-The discovery by Prof. 
Roentgen of Wurtzburg of a new form of radiant 
energy emanating from a Crooke's tube has given 
rise to the new science of Roentgenology. He 
found that this new form of energy was capable 
of penetrating substances formerly considered 
opaque, in degrees varying with the vaccum in 
the tube and the density of the object penetrated. 
It affected the silver salts of the photographic 
plate, and the fluorescent salts spread upon a screen 
called a fluoroscope with proportionate degrees of 
intensity and thus lent itself readily to use in 
diagnosis. He did not invent any apparatus, 
but showed that the rays he discovered could be 
applied to physical diagnosis. 
Roentgenology is the application to diagnosis and 
therapy of the unknown (X) or Roentgen rays. 
This science is subdivided into (a) Roentgenography, 
physical diagnosis by means of these rays and the 
photographic plate, (6) Roentgenoscopy, their use 
with the fluoroscope, and (c) Roentgenotherapy, 
treatment by this form of irradiation. 
The development of apparatus has rendered 
the rays more powerful and less dangerous to the 
patient in experienced hands, but more dangerous 
Prognosis.-As to ultimate cure, favorable. 
As to duration, guarded. Most cases persist from 
6 months to 1 1/2 years. 
Treatment.-The treatment consists of (1) daily 
soap and hot water cleansings; (2) epilation of 
diseased hairs; and (3) application of parasiticide 
ointments and lotions. The scalp will bear rem- 
edies of greater strength than the nonhairy sur- 
faces. 
The head should be washed vigorously each day 
with soap and hot water. For this purpose 
ordinary soap may be employed or, preferably, a 
soap containing tar. This accomplishes the double 
purpose of cleansing the scalp of fungus and scales 
and of preventing surface extension. The para- 
siticide effect of the washing may be increased by 
allowing the soapsuds to remain upon the scalp for 
from 15 to 20 minutes. The hair should be cut 
short in order to facilitate the application of the 
various medicaments. 
The diseased hair should be extracted either 
with a broad-blade epilating forceps or the small 
end of a spoon and the thumb. Epilation is of 
value in effecting the removal of a considerable 
amount of fungus in the hair, in opening the folli- 
cle, and permitting the ingress of the parasiticide 
application. 
The choice of the particular ointment or lotion 
is not a matter of great importance. It is the 
thorough and persevering use of the same that 
brings success. Sulphur, mercury, beta-naphthol, 
carbolic acid, resorcin, salicylic acid, tar, chrysaro- 
bin, and a host of remedies have been used, but 
those above mentioned are the most valuable. 
The following ointment will be found useful in 
most cases:' 
3. Precipitated sulphur, 3 j to ij 
Petrolatum, § j. 
This is to be rubbed into the patches vigorously 
once or twice a day. One may use, in conjunction, 
a lotion of sodium thiosulphate, one dram to the 
ounce. Beta-naphthol is a remedy of great value, 
and has the advantage of being free from odor: 
1J. Beta-naphthol, 3 j 
Petrolatum, § j. 
A lotion of the bichlorid of mercury may often 
be employed with advantage. Beginning with 
1 grain to the ounce, one may gradually increase 
to 4 or 5 grains. 
A word as to the prevention of the spreading of ROENTGEN RAYS 
ROENTGEN RAYS 
both to patient and operator in the hands of the 
inexperienced. Their use must therefore be con- 
fined to those who have acquired special knowl- 
edge, and only in such hands can valuable results 
be expected. 
The Dangers of the Roentgen Rays.-The ad- 
vancement in technic and apparatus practically 
limits the danger to those who have little or no 
experience. The increase in power, which makes 
diagnosis now possible by an exposure of only a 
few seconds, augments the danger in the hands 
of the inexperienced. Medical knowledge is es- 
sential to their valuable application in diagnosis 
and in therapy; it is needed to appreciate the 
change produced, and to regulate the dose 
accordingly. 
The series of lamentable, often fatal, accidents to 
operators has shown the necessity for special 
training. Though the patient is less liable to 
injury from the more powerful apparatus, the 
danger to the untaught operator is greater. 
The Apparatus.-The evolution of efficient 
apparatus has been rapid. The Ruhmkorff coil 
of the physical laboratory even when improved 
was crude and difficult to handle. The modern 
Roentgen generator is more powerful and yet 
simpler in manipulation. It is a machine, as 
simple to run as an ordinary electric motor, with- 
out the disadvantages and complications of inverse 
currents, electrolytic or mechanical interrupters, 
and the constant expense and annoyance atten- 
dant upon their regulation and repair. It fur- 
nishes an unlimited supply of unidirectional high- 
potential current necessary to energize the 
Roentgen tube. It is an efficient and easily con- 
trolled mechanism of great power. 
The problem of effective technic has, however, 
become more rather than less complicated, since 
more efficient modifications in its application 
have been made, thus rendering diagnosis more 
accurate. 
Such efficient apparatus can be run in con- 
nection with any commercial electric lighting or 
power circuit, but must be adapted to the particular 
current to be employed. 
The Roentgen Tube.-This is a modified Crooke's 
tube adapted to the purposes of Roentgenology. 
It is now the most complicated part of the appara- 
tus to understand and requires efficient technic. 
Since the rays emanating from the Roentgen tube 
in action vary with its vacuum in penetration and 
therapeutic value, they must be adapted to the 
particular form of diagnosis to be made and to the 
disease to be treated. 
Other essential accessory pieces of apparatus 
have been developed, the milliamperemeter to 
measure the amount of current passing through 
the tube; the static voltmeter to measure the ten- 
sion of the current and the relative vacuum of 
the tube, i. e., the penetrating power of the rays 
while the tube is in operation; filters, which by re- 
moving undesired rays have increased the safety 
and efficiency of the rays in diagnosis and 
treatment. 
These contrivances, while reducing the time of 
exposures in diagnosis from minutes to fractions 
of a second, have rendered technic essential and 
yet more involved. 
In practice Roentgenology is divided into diag- 
nosis and therapy. 
Roentgenography is a method of physical diag- 
nosis by means of the Roentgen rays and the photo- 
graphic plate. A Roentgenogram is a photographic 
negative produced by this method upon which 
the Roentgen diagnosis is based. A Roentgeno- 
gram can be produced by any one who can run 
the apparatus, but one upon which a valuable 
diagnosis can be based can only be made by a 
medically educated operator knowing the es- 
sential special technic. For diagnostic purposes 
there is desired not a picture, but a Roentgeno- 
gram which shows the tissues in which a lesion is 
supposed to exist. 
The value of the Roentgen diagnosis is depen- 
dent upon the medical training of the operator, 
his technical ability in employing this method and 
his clinical experience in translating the resulting 
data. 
The tube must be placed in proper relation to 
the part to be examined and the photographic 
plate; the quality of rays must be adapted to the 
tissues to be studied; the exposure must be cor- 
rect, in order to determine the presence or absence 
of the supposed pathologic lesion. Anatomical, 
clinical and special technical knowledge combined 
with experience are therefore essential to an 
accurate Roentgen diagnosis. 
Stereoroentgenograms are pairs of Roentgeno- 
grams so made that when each is viewed by one 
eye of the observer in the stereoscope the effect 
of a true perspective is produced. By this 
method the distortion produced by the diver- 
gence of the rays emanating from the tube is cor- 
rected and transformed into a true perspective or 
a realization of the third dimension. It has the 
advantage of showing the lesion in its true ana- 
tomic relations, not as a shadow, but, as it ■were, 
within a semi-transparent body. Thus the posi- 
tion of the bones in dislocations, the fragments in 
fractures, the location of foreign bodies, or the 
minute masses of tubercle in tuberculosis of the 
lungs are seen in their true anatomic relations to 
the surrounding normal structures. 
The development of more efficient apparatus 
has shortened the time of exposure, so that volun- 
tarily movable organs can be shown in sharp 
detail after exposure of a fraction of a second in 
most examinations; while no exposure, except in 
very stout individuals, should exceed 15 to 20 
seconds, unless taken with portable apparatus. 
The examination of patients in their homes is easy 
and practical, but necessitates less powerful 
apparatus and longer exposures. 
Applications of Roentgenography.-In internal 
medicine it has rendered diagnosis more accurate 
by clearly demonstrating the size, position, and 
form of aneurysms, aortic dilatations, changes in 
the size and position of the heart, mediastinal 
new growths, and strictures and new growths of 
the esophagus. In the lungs it locates and shows 
all macroscopic, pathologic changes, while in 
tuberculosis of the lungs it definitely determines ROENTGEN RAYS 
ROENTGEN RAYS 
the presence, position and size of areas of con- 
gestion, consolidation, softening and cavity forma- 
tion, as well as the effect of adhesions and con- 
tractions upon the mediastinal viscera and the 
diaphragm. Early enlargement of the peri- 
bronchial lymph nodes can be shown before they 
can be detected by physical signs, while stereo- 
scopic pictures reveal minute clusters of tubercle 
scattered throughout the lung. 
The application of this method to the stomach 
after a bismuth meal has been given, reveals its 
normal or pathologic position and the presence or 
absence of motor insufficiency, pyloric obstruc- 
tion, malignant disease, pathologic stricture of the 
stomach and intestines, or ptosis of these organs. 
In the kidney, enlargements, displacements, 
abscesses, new growths and calculus formations 
can be revealed by this method. In renal cal- 
culus it is admittedly the most accurate method 
known. It determines the size, position and 
number of the calculi present in the kidney, 
ureter, or bladder, and no surgical intervention 
or expectant treatment is sanctioned without 
its employment. The differentiation between 
sthenic and asthenic forms of arthritis is another 
very valuable aid to internal medicine. 
In surgery it is of great value in locating foreign 
bodies, in definitely determining the lines of 
fracture, the position and number of the frag- 
ments, the efficiency of reduction and of fixation 
appliances. The same is true of dislocations, while 
its value in excluding such injuries should not be 
overlooked. 
It differentiates between the several forms of 
bone disease, showing the location, extent, and 
nature of cysts, tuberculosis, osteomyelitis, 
syphilis, malignant diseases. 
In orthopedic surgery it is peculiarly adapted 
to the determination of the extent, location and 
character of bone defects, distortions and necroses, 
differentiating, for example, between achondro- 
plasia and osteomyelitis, and elucidating the 
extent and character of the deformity present. 
It detects supernumerary bones and shows con- 
genital malformations, defects and dislocations. 
In otology and rhinology it reveals disease of 
the accessory sinuses, and the presence of ab- 
scesses and bone absorption in the mastoid cells. 
Medicolegal Value.-The Roentgen rays pro- 
duce a visible picture of pathologic conditions 
which could formerly be expressed only in the 
mental pictures formed by other methods of 
physical diagnosis. In medicolegal testimony 
it has the advantage of being evidence which can 
be seen and the meaning of which can be demon- 
strated to a jury. The question of interpretation 
is the only one capable of argument, and for that 
reason it is essential that expert testimony should 
be on hand for both sides, when any question of 
interpretation can be raised. In the majority 
of cases, especially of bone injury, the interpreta- 
tion is obvious. This method possesses an 
additional advantage in that it shows not only 
the present condition, but also the extent of the 
original injury-a point which should always be 
brought out in malpractice suits. Its power to 
demonstrate the absence of any bone injury is 
particularly valuable when such an injury is 
falsely made the basis of a suit for damages. 
Since this method has been admitted to be 
of scientific value and permitted as evidence in 
courts of justice, its employment in all cases of 
fracture forms the greatest safeguard to the sur- 
geon against suits for malpractice. It furnishes 
evidence of the condition before treatment, the 
seriousness of the bone lesion, and if plates are 
made after the fracture is set and immobilized, 
demonstrates that efficient treatment has been 
instituted. The inference that the injury to 
function is proportionate to the distortion shown 
in the Roentgenogram is erroneous, for bones 
united with apparent distortion are frequently 
found after injury in limbs that have perfect 
function. The fact that the injury to ligaments 
and soft tissues is not shown by the Roentgeno- 
gram should be made clear, although they may 
be inferred from the injury demonstrable. It is 
therefore obvious that the evidence produced by 
this method cannot form the basis for determining 
the amount of functional injury sustained by the 
patient. 
Roentgenotherapy.-The treatment of disease 
by means of the irradiations from a Crooke's or 
Roentgen tube. 
The therapeutic value of the Roentgen rays 
has been so clearly demonstrated that this de- 
partment of Roentgenology is firmly established. 
Pathologic studies have demonstrated that the 
Roentgen rays have a destructive action upon 
all tissues of low vitality and hence upon all cells 
resulting from disease, at the same time stimulat- 
ing normal cells to greater activity. Thus this 
agent increases the local resistance of the normal 
tissues while it devitalizes the pathologic. This 
local action on metabolism in a measure accounts 
for the many successful applications of this agent. 
The effective application of the Roentgen rays 
for therapeutic purposes demands careful study 
and experience. By timidity in their application 
the diseased cells instead of being destroyed may 
be stimulated to greater activity. By too severe 
treatment the normal cells may be injured and the 
local vitality and resistance so essential to recovery 
may be destroyed. The difficulties attending the 
proper use of this method account for divergent 
reports of success and failure. 
The results obtained show that Roentgenother- 
apy is effective in many serious and especially 
chronic conditions intractable to other methods. 
The field of this therapeutic agent is so wide that 
only a summary of some of its successful appli- 
cations can be given. 
In malignant disease some remarkable results 
have been produced. It has cured many in- 
operable and hopeless cases, while as a palliative 
measure it is the most efficient in affording, when 
properly applied, relief from pain. As postopera- 
tive treatment, its beneficial effect in malignant 
cases is shown in the reduced mortality rate of 
such cases. These results have led to its appli- 
cation in the earlier stages of the disease with pro- 
portionately better results. ROSE 
RUBELLA 
In epithelioma (g. v.) and rodent ulcer it has 
been shown by many series of permanent results 
to be superior to other methods of treatment. 
In tuberculous cervical adenitis it can be em- 
ployed efficiently in the early stages of disease, 
when consent to radical treatment cannot be 
obtained, and while the patient is under medical 
treatment. 
Successful results have been obtained in cases 
of recurrence after repeated operations. It pro- 
duces healing in persistent sinuses and ulcerations 
that have defied surgical treatment. In these 
conditions it is therefore the method of choice. 
In lupus vulgaris and lupus erythematosus it is 
the most effective treatment known, and produces 
permanent results with less scar formation. 
In other cutaneous lesions such as acne, eczema, 
pruritus, ringworm, sycosis, etc., the results are 
remarkable, especially in the chronic forms that 
have resisted all other medication; this is especially 
true of the indurated acne and dry eczemas. 
It has also been found valuable in diseases such 
as the neuralgias and neuroses, goiter (both 
simple, and exophthalmic), as well as other con- 
ditions, affording, in many instances, relief from 
pain, and permanent cure. To obtain the best 
results, however, treatment should be instituted 
in the earliest stages of disease. 
ROSE (Rosa).-Represented in official phar- 
macy by the petals of one species and the volatile 
oil from another. 
Rosa Damascena, Damask Rose, is the source of 
the official oil of rose, which is distilled from the 
fresh flowers. 
Rosa Gallica, Red Rose, is the petals of Rosa 
gallica, collected before expanding. They con- 
tain an aromatic oil, tannic and gallic acids, 
quercitrin, coloring matter, salts, etc. 
Rose water has no strictly medical properties, 
but is an agreeable excipient for lotions, collyria, 
and urethral injections. The ointment, commonly 
termed cold cream, is a pleasant emollient and 
protective agent, generally used for chapped 
hands and other superficial skin affections. Red 
Rose is classed among the astringents, as it con- 
tains an appreciable amount of tannic and gallic 
acids. A compound infusion, containing sugar 
and dilute sulphuric acid, was formerly official, and 
is used as an agreeable gargle for the throat and 
mouth in inflamed and ulcerated conditions. The 
chief uses of the rose preparations are as vehicles 
for other agents, or to impart flavor and odor to 
extemporaneous prescriptions. 
Preparations.-R. Oleum, Attar of Rose, is a 
volatile oil distilled from the fresh flowers of Rosa 
damascena. It is a pale-yellowish, transparent 
liquid, having a strong odor of rose, a sweetish 
taste and a slightly acid reaction, but slightly 
soluble in alcohol. It consists of an aromatic 
oxygenated eheopten and an odorless solid 
stearopten (rose-camphor). Being very expen- 
sive it is much adulterated with other volatile oils. 
It is used chiefly for perfuming cosmetic prepara- 
tions, ointments and lotions, and as the basis of 
the following three preparations. R. Aqua 
Fortior, Triple Rose Water, is water saturated 
with the volatile oil of rose petals. An agreeable 
excipient and flavoring agent. Dose, 1/2 to 4 
drams. R. Aqua consists of equal volumes of the 
preceding and distilled water, mixed together 
immediately before use. It is an ingredient of 
mistura ferri composita. Dose, 1 to 8 drams. 
Unguentum Aquae R., Cold Cream, has of stronger 
rose water 19, expressed oil of almond 56, sperma- 
ceti 12 1/2, white wax 12, and sodium borate 1/2. 
Fluidextractum R., prepared from red rose with 
glycerin and diluted alcohol. Dose, 5 to 60 
minims. Confectio R., has of red rose 8, sugar 
64, honey 12, stronger rose water 16, beaten 
together into a mass. Dose, 10 to 60 grains. 
Mel. R., Honey of Rose, has of the fluidextract 12, 
and clarified honey to 100. Dose, 1 to 2 drams. 
Syrupus R., has of the fluidextract 12 1/2 per- 
cent. Dose, 1 to 2 drams for flavoring. Red rose 
is an ingredient of Pil. Aloes et Mastiches. The 
confection is an ingredient of Pil. Aloes et Ferri. 
ROSE COLD.-See Hay-fever. 
ROSEMARY (Rosmarinus).-The leaves of R. 
officinalis. Its properties are due to a volatile oil 
and a resinous principle. Rosemary was formerly 
considered emmenagog, galactagog, and diuretic. 
It is chiefly used as an external stimulant in lini- 
ments and lotions, especially to the scalp, in 
alopecia (usually combined with cantharides). 
R., Oleum, the volatile oil. Dose, 1 to 5 minims. 
ROSEOLA.-A rose rash. See Erythema, 
Rubella, Syphilis, Typhoid Fever, Vaccina- 
tion. 
ROSMARINUS.-See Rosemary. 
ROUGH ON RATS.-A paste for poisoning rats, 
occasionally used as a means of suicide. The 
active ingredient in most of these pastes is 
arsenic, and acute arsenic-poisoning results from 
its ingestion. See Arsenic. 
ROUND LIGAMENTS.-See Alexander's 
Operation. 
ROUND-WORMS.-See Worms. 
RUBEFACIENTS.-Substances that by irritation 
of the ends of the nerve filaments of the skin cause 
distention of the capillaries and reddening of the 
skin. If left too long in contact with the surface, 
exudation between the cuticle and true skin may 
ensue, when the agent becomes a vesicant; or it 
may destroy the tissue and form a slough, when it 
is an escharotic. Muscular atrophy may be in- 
duced by rubefacients. The following is a list: 
Mustard, capsicum, camphor, ammonia, mezereon, 
arnica, alcohol, ether, chloroform, iodin, menthol, 
oil of cajuput, oil of turpentine, volatile oils, pitch, 
friction, and hot water. See Counterirritation. 
RUBELLA (Rbtheln; German Measles; Roseola). 
-An acute infectious disease of a mild nature,*and 
characterized by slight inflammation of the mucous 
membrane of the conjunctiva, mouth, nose, and 
fauces; enlargement of the cervical glands; mild 
fever, and a papular eruption of the skin. 
Etiology.-Rubella is contagious, and may occur 
in epidemics or sporadically. Though probably 
microbic in origin, the specific organism has not 
been isolated. It is spread by the cutaneous 
exhalations and breath and by fomites, especially 
in hospitals or crowded quarters; it is very con- RUBELLA 
RYE 
tagious, but in family practice it is but slightly so, 
the cases often being confined to a single household. 
The incubation period is from 10 to 12 days, 
though it may vary; but as a rule it is longer 
than in measles. 
The stage of invasion is from 1 to 3 days, but in 
mild cases the appearance of the rash may be 
the first indication of the disease. 
Symptoms.-Usually for a period of a few days 
before the rash appears there will be chilliness, 
pain in the legs and back, a dull heavy feeling, and 
perhaps slight fever. There may be suffusion of 
the eyes and coryza. Enlargement of the tonsils 
and of the cervical lymph-glands are common. 
Just before or with the appearance of the rash 
there is a rise in temperature-99° to 100° F., or in 
severe cases 102° to 103° F. These symptoms in 
certain cases may be very mild or altogether want- 
ing, the appearance of the rash, as stated, being 
the first sign of infection. The rash first appears 
on the face and extends downward over the body. 
In some cases, however, only one part of the body 
may show any eruption; in others every part, 
including the palms of the hands and soles of the 
feet, may be covered. The roof of the mouth and 
fauces usually are more or less generally covered 
with the rash. 
The eruption is multiform, confluent, and of a 
pale or rosy red color. The patches do not have 
any regular shape or form, and the skin between 
them may be hyperemic and itching. It reaches 
its height on different parts of the body in succes- 
sion, fading in one part while appearing in another. 
The duration of the rash is from 2 to 5 days. 
Slight branny desquamation usually appears. 
A slight brownish pigmentation often follows the 
rash, but disappears in a few days. 
The temperature varies, but usually there is 
fever-100° to 102° F.-while the eruption is at 
its height. 
Sore throat of greater or less severity is usually 
present, as is also a dry bronchial cough. In 
severe cases vomiting may occur during the erup- 
tive period, but, as a rule, the constitutional 
effects are very slight, the patient with difficulty 
being kept in bed. The duration is 3 days to a 
week; when uncomplicated, the convalescence is 
rapid. The complications that may occur are 
severe bronchitis, pneumonia, and gastrointestinal 
catarrh; but they are not frequent, most children 
escaping any serious consequences of the affection. 
Diagnosis.-In sporadic cases there is no rule 
by which rubella may positively be distinguished 
from measles, or in certain cases from mild 
scarlatina. 
The milder onset, the character of the eruption, 
and mild symptoms throughout, with the ab- 
sence of complications and sequels, will, however, 
serve to differentiate it from a well-marked case 
of either of these diseases, with their character- 
istic onset, rash, and course. The eruption does 
not last so long as that of measles. There is more 
distinct mottling than in scarlatina. 
The following table will be a guide in distin- 
guishing rubella from erythema and urticaria: 
Rubella. 
Erythema. 
Urticaria. 
Rash occurs first on 
face. 
Coryza 
No itching at first. 
Contagious 
Microbic origin.... 
On hands and feet. 
None 
Burning pain.. .'.. 
Not so 
Reflex origin 
In wheals on arms 
and legs. 
None. 
Intense itching. 
Not so. 
Gastric origin. 
The prognosis in uncomplicated cases or except 
when occurring in children weak and debilitated 
from other causes, is invariably favorable. 
Treatment.-The child should be confined to a 
room with a temperature from 68? to 70° F., and 
when feverish kept in bed. A daily warm bath 
or warm sponging, followed by inunctions of 
cacao-butter, should be given, and the bowels kept 
open with small doses of calomel, to which, when 
there are fever and restlessness, should be added 
phenacetin or acetanilid, 1/2 grain for each year 
of the child's age, every 3 hours. When there 
is coryza or sore throat, the patient should be 
treated with a mild alkaline wash, and for the 
cough, when present, a mixture as given for 
measles should be prescribed. The child should 
be isolated for a period of at least 2 weeks. 
RUBEOLA.-See Measles. 
RUBUS (Blackberry).-It contains more than 
10 percent of tannic acid. It is very astringent, 
and is highly esteemed in summer and infantile 
diarrheas. Dose, 10 to 30 grains. R. Fluid- 
extractum. Dose, 10 to 30 minims. R. Syrupus. 
Dose, 1/2 to 2 drams. 
RUMINATION (Merycism).-A remarkable and 
rare condition in which patients regurgitate and 
chew the cud, like ruminants. It occurs in 
neurasthenic or hysteric persons, epileptics, and 
idiots. It may be hereditary. Certain persons 
have the power of returning food from the stomach 
to the mouth at will. 
In several instances recorded the return of the 
food took place in about 15 minutes after finishing 
the meal, and usually had no acid taste, and had 
not undergone any digestion. The medical 
treatment of the condition consists in the use of 
ipecacuanha and aloes twice daily, and adminis- 
tration of a tonic before meals. 
RUPIA.-A term used to denote a peculiar 
variety of pustular syphiloderm. See Syphilis. 
RUPTURE.-See Hernia. 
RUPTURE OF UTERUS.-See Postpartum 
Hemorrhage. 
RYE.-See Ergot. SABAL 
SALICYLIC ACID 
s 
SABAL.-The fruit of Serenoa serrulata, the 
saw-palmetto. Sabal is sedative, nutritive, tonic 
and diuretic. It has been used with much benefit 
in the enuresis of old men, enlargement of the 
tonsils, spasmodic croup, chronic sore throat, and 
gonorrhea. The elixir saw-palmetto and santal 
compound is highly esteemed in incontinence of 
urine, vesical catarrh, and urethritis. Dose of 
the fluidextract, 1 dram. 
SABINA.-See Savine. 
SABROMIN.-Dibrombehenate of calcium. It 
has the same action as the bromids, but its effect 
is less rapid and more prolonged. It is said to be 
free from the. disadvantages of the bromids. 
Dose the same as that of potassium bro mid. 
SACCHARATE.-Compound of saccharic acid 
and a base, or compounds of cane-sugar with a 
base. S. of Iron (ferrum oxydatum saccharatum 
solubile, Ger. Ph.), a compound of cane-sugar and 
iron, important as an antidote for arsenic. S. of 
Lead, a salt of saccharic acid and lead, used in 
forming the nitrosaccharate of lead, which has been 
vaunted as a safe and effective solvent for urinary 
calculus. S. of Lime, a compound of cane-sugar 
with lime. A syrup charged with it has been rec- 
ommended as a cure for chronic rheumatism. A 
solution of this compound is a good antidote in 
carbolic acid poisoning. Saccharated Carbonate of 
Iron, a greenish-gray powder containing sulphate 
of iron. S. lodid of Iron, iodid of iron with milk- 
sugar. S. Pepsin, milk-sugar with pepsin from the 
stomach of the hog. 
SACCHARIN. C8H4/^q >NH. - Benzosulphi- 
nid, derived from coal-tar, occurring as six-sided, 
colorless tablets, melting at 224° C. It is 280 
times sweeter than cane-sugar. It is used as a 
substitute for sugar in diabetes, and is recom- 
mended for use in the treatment of corpulency 
and gout. It is also antiseptic, and has been 
found useful in erysipelas, septic fever, and 
gonorrhea. Dose, 1/2 to 5 grains. 
SAFFRON.-See Colchicum. 
SAFROL. C10H10O2.-The methylene ether of 
allyl pyrocatechol, found in oil of sassafras and 
other oils. It is used in headache, neuralgia, and 
subacute rheumatism. Dose, 1 to 10 minims. It 
is also employed for perfuming soap. 
SAINT VITUS' DANCE.-See Chorea. 
SAJODIN.-Monoiodobehenate of calcium. A 
substitute for the iodids. Although containing a 
smaller quantity of iodin than potassium iodid, 
sajodin is claimed to be equally efficient. It is 
said to have been proven exceptionally free from 
the unpleasant and deletereous by-effects of the 
iodids. It is used for the same purposes as 
potassium iodid. Dose, 15 to 45 grains daily. 
SALICIN.-A glucosid occurring in the bark and 
leaves of willows and some poplars. It forms 
shining crystals that dissolve easily in hot water 
and alcohol, and melt at 198° C. Its taste is bitter. 
It possesses tonic properties, and is used as a sub- 
stitute for salicylic acid in the treatment of rheu- 
matism. Dose, 10 to 30 grains. 
SALICYLIC ACID. C7H6O3.-Orthooxybenzoic 
acid; occurs in a free condition in the buds of 
Spiraea ulmaria, in the oil of wintergreen, and in 
other varieties of gaultheria. It is also obtained 
synthetically. It consists of four-sided prisms, 
and crystallizes readily from hot water in long 
needles. Is soluble in water, and very soluble in 
chloroform; melts at 155° to 156° F. It is a power- 
ful antiseptic and is used as such in surgery and 
dermatology in solution and ointment. It is much 
used in the treatment of acute articular rheuma- 
tism and myalgia. Dose, 5 to 15 grains. 
Lithii Salicylas, a white, or grayish-white 
powder, odorless, sweetish, very soluble in 
water and in alcohol. Dose, 5 to 30 grains. 
Sodii Salicylas, a white, amorphous powder 
soluble in 3/4 of water and in 6 of alcohol, also in 
glycerin. Dose, 5 to 30 grains. Strontii Salicylas,' 
a white, crystalline powder, soluble in 18 of 
water and in 66 of alcohol. Dose, 5 to 30 grains. 
Methylis Salicylas, artificial oil of wintergreen, is 
an ester, produced synthetically; and is the prin- 
cipal constituent of oil of gaultheria and oil of 
betula. It is soluble in all proportions in alcohol 
or glacial acetic acid. Dose, 5 to 30 minims, sus- 
pended in sugared water. Phenylis Salicylas, salol, 
is the salicylic ester of phenyl, and occurs as 
a white, crystalline powder, odorless and almost 
tasteless, nearly insoluble in water, soluble in 10 
of alcohol, and very soluble in ether, chloroform 
and oils. On being warmed with an alkali it splits 
up into salicylic acid 60, and phenol 40. Dose, 5 to 
15 grains, frequently repeated, in compressed tab- 
lets or in cachets, or suspended by mucilage of 
acacia or of tragacanth. See Salol. Physostig- 
minae Salicylas. See Physostigma. Oleum Betulae, 
oil of sweet birch, is a volatile oil distilled from the 
bark of Betula lenta, the sweet birch. It is identical 
with methyl salicylate and nearly identical with 
oil of gaultheria. Dose, 5 to 30 minims. Oleum 
Gaultheriae, oil of wintergreen, consists almost en- 
tirely of methyl salicylate, and is nearly identical 
with the. preceding. See Gaultheria. 
Sodium Salicylate is more soluble than the acid 
and less irritant to the stomach, while in doses 
about 50 percent larger it is equally efficient. It is 
employed in 3- to 5-grain doses internally after 
meals, to arrest gastric fermentation and to pre- 
vent acidity and flatulence. It is used instead of 
the acid in acute inflammatory rheumatism, mus 
cular rheumatism, phlebitis, rheumatic neuritis 
and other irregular forms of rheumatism, with im- 
mediate benefit in most cases, and it sometimes 
gives temporary relief in chronic rheumatism. In SALIFORMIN 
SALPINGITIS 
gout and its manifestations, especially migraine and 
sciatica, it frequently proves highly effective; and 
it has been used with satisfaction in cases showing 
a tendency to the formation of gall-stones. It is 
useful in the glycosuria of gouty subjects, and in 
the nervous irritability of lithemic persons. It is 
ranked as almost specific in pneumonia by many 
practitioners, and is very efficient in non-syphilitic 
inflammations of the eyeball, whether rheumatic 
or not, especially interstitial keratitis, if given in 
large doses. It is highly efficient in quinsy, and 
has been commended as an alterative diuretic for 
the removal of serous pleuritic effusions. When 
large doses are prescribed the patient should be 
kept in bed, and brandy, strychnin, and digitalis 
should be administered to counteract its depres- 
sant action. The salicylates are contraindicated 
in meningeal inflammation or congestion, middle 
ear disease, renal insufficiency, albuminuria, and 
nephritis. 
Lithium Salicylate is believed to be particularly 
applicable in lithemia, gout, rheumatic arthritis, 
and the various manifestations of the uric acid 
diathesis. 
Strontium Salicylate is not apt to derange the 
stomach, but is too slow in its action to be of 
value when a rapid and powerful influence is 
desired. In 5-grain doses it is one of the best 
intestinal antiseptics, giving better results than 
Salol or naphthalene. In 10- to 15-grain doses it 
is one of the most efficient salicylates for chronic 
gout and lithemia with intestinal indigestion 
(Wood). 
SALIFORMIN (Urotropin Salicylate).-Sali- 
formin is a genitourinary antiseptic and is recom- 
mended as a uric-acid solvent. Its action is sim- 
ilar to that of a mixture of hexamethylenamin 
and salicylic acid, for it is largely hydrolyzed into 
its constituents in the presence of water. Dose, 5 
to 30 grains. 
SALINE INFUSION.-See Infusion of Salines. 
SALINES.-See Cathartics, Mineral Waters. 
SALIPYRIN.-A white powder, the salicylate of 
antipyrin, consisting of 57.7 parts of salicylic acid 
and 42.3 parts of antipyrin. It is readily soluble 
in water and has been recommended as an analgesic 
and antipyretic in doses of 10 to 20 grains. 
SALIVATION.-An excessive secretion of saliva. 
It may be produced by certain poisons, by such 
drugs as mercury and pilocarpin, or by nervous dis- 
turbances. See Mercury (Poisoning), Sialagogs. 
SALOL (Phenyl Salicylate). Cl3H10O3.-A white, 
odorless, crystalline substance. It is used as an in- 
testinal antiseptic and as a substitute for salicylic 
acid, being less irritating to the stomach. Dose, 
5 to 15 grains. It is decomposed in the intestines 
into salicylic acid and phenol. On this account 
it has been employed to test the motor power of 
the stomach. A few grains are given in capsule 
and the urine is tested at intervals for the de- 
composition products of salicylic acid. 
Salol is one of the most efficient remedies for 
duodenal catarrh, catarrh of the bile-ducts, and 
catarrhal jaundice; also in the biHous form of sick 
headache, and in some forms of neuralgia. It is a 
remedy of very great value in typhoid fever; dis- 
infecting the ulcerated intestines, it promotes the 
healing process therein and hinders reinfection. 
It is highly recommended in dysentery, in cholera, 
and in infantile diarrhea. Given in the latter 
affection, a dark staining of the child's diapers is 
often noticed, which is due to the development of 
carbolic acid from the remedy. Its greatest 
power is manifested over acute rheumatism, in 
which disease many clinicians maintain that it has 
no superior, if given in 15- to 30-grain doses, up to 
2 drams in the 24 hours, and continued for some 
time after the acute symptoms have subsided. 
In large doses, however, it is liable to induce 
symptoms of carbolic acid poisoning, which may 
be met by administering sodium sulphate or any 
other sulphate. It proves to be an efficient dis- 
infectant in catarrh of the bladder, its constituents 
being excreted with the urine, and coming in con- 
tact with the vesical mucous membrane for a con- 
siderable length of time. It is much quicker in 
its action upon the urine than ammonium benzoate, 
as in a day or two, ordinarily, the urine loses its 
foul odor and alkalinity and becomes clear. 
Externally, it is employed as an antiseptic and 
deodorant powder, against impetigo, eczema, 
sycosis, and other skin-diseases; and has done good 
service as an insufflation in the treatment of ozena. 
In spirituous solutions (5 percent) it is used with 
various flavoring agents in the preparation of 
mouth-washes and dentifrices; and it also enters 
into the composition of soaps, face powders, and 
other toilet articles. 
In cholera morbus: 
I|. Salol, 3 j 
Bismuth subnitrate, 3 ij 
Chalk-mixture, add enough 
to make 3 iij. 
Two teaspoonfuls every 2 hours. 
SALOPHEN.-A derivative of salicylic acid, 
occurring as minute, white, crystalline scales, 
odorless and tasteless, insoluble in water, but 
soluble in alcohol. It is decomposed by alkalies. 
The actions of salophen resemble those of phenyl 
salicylate (salol). It is not changed in the 
stomach, but is broken up in the intestine, liberat- 
ing salicylic acid and acetylparamidophenol, which 
is not toxic. Its dose is 5 to 15 grains up to 1 or 
11/2 drams in 24 hours. It is used as a substitute 
for salol, than which it is said to be far less poison- 
ous. It can be very effectually combined with 
phenacetin in the treatment of neuralgia. In long- 
standing sciatica a 10 percent solution hypoder- 
mically into the gluteal muscles has given good 
results. It has been employed with decided bene- 
fit in intestinal dyspepsia with flatulence. See 
Salol. 
SALOQUININ.-(Salochinin.) The salicylic ester 
of quinin. It is a tasteless, crystalline powder, 
insoluble in water. It is said to possess the virtues 
of quinin as well as those of salicylic acid, and is 
used efficiently as an antipyretic and antineuralgic. 
Dose, 5 to 30 grains. 
SALPINGITIS.-See Fallopian Tubes (In- 
flammation) . SALTATORY SPASM 
SARCOMA 
SALTATORY SPASM.-See Nervous Diseases 
(Examination). 
SALTPETER.-Native potassium nitrate. It 
occurs in colorless, hard, rhombic prisms of sharp, 
saline, and bitter taste, and is soluble in about 
9.5 of water at 59° F., or in 4 of boiling water, but 
is insoluble in alcohol. The dose is from 20 grains 
to 1/2 dram, well diluted. It is a refrigerant 
diaphoretic and diuretic in febrile and inflamma- 
tory affections, especially of the trachea and 
bronchi. It is useful in asthma, pneumonia, 
and rheumatism. 
The fumes of the following burning niter paper 
are serviceable in spasmodic asthma: 
1$. Potassium nitrate, 2 1/2 parts 
Powdered belladonna leaves, 1/2 part 
Powdered stramonium leaves, 5 parts 
White sugar, pulverized, 1/2 part. 
Dissolve the niter in just enough water to make 
a saturated solution, mix with the leaves, dry 
into a coarse powder, and add the sugar. 
A small quantity is to be placed on a tin plate, 
ignited, and the smoke inhaled. 
Poisoning.-There is no chemic antidote. 
Emetics or stomach-pump, demulcent drinks, and 
emollient enemata, particularly milk, should be 
administered. Opium is the best antagonist for 
the subsequent depression. Aromatics and brandy 
may be given. See Potassium. 
SALT RHEUM.-See Eczema. 
SALVARSAN.-See Syphilis. 
SANDALWOOD (Santalum).-The wood of a 
species of Santalum album and S. citrinum, or 
yellow sandalwood. It yields oil of santal, an 
astringent oil, useful in chronic bronchitis and 
gonorrhea. It is often adulterated with oil of 
cedar. Dose of the volatile oil, 5 to 15 minims, 
in emulsion or capsule. S. rubrum, red saunders, 
the wood of Pterocarpus santolinus, imparts a 
brilliant red color to ether and alcohol. 
SANGUINARIA (Blood-root).-The dried rhiz- 
ome of S. canadensis. It contains the alkaloids 
sanguinarin, chelerythrin, protopin, and homo- 
chelidonin. Dose of the powdered root as an 
expectorant, 1 to 5 grains; as an emetic, 10 to 30 
grains; best given in pill. In large doses it causes 
vomiting and purging. Toxic doses cause con- 
vulsions, and then paralysis; death results from 
failure of respiration. As a stomachic and hepatic 
stimulant it is employed in small doses (3 drops of 
the tincture). It is used as an expectorant in 
chronic bronchitis. Chronic nasal catarrh, asthma, 
and acute bronchitis are remarkably amenable to 
the influence of sanguinaria, particularly when it 
is given in 10-drop doses of the tincture. It is 
used as a specific emetic in croup, though its action 
is uncertain and harsh. It is incompatible with 
alkalies, tannin, and most of the metallic salts. 
Its antagonists are amyl nitrite, opium, atropin, 
and such drugs as antagonize the depression of the 
circulation and the local irritant action. 
Preparations. Fluidextract.-Dose, 1 to 5 
minims as an expectorant; 10 to 60 minims as an 
emetic (cautiously). S., Tinct., 10 percent strong. 
Dose, 5 to 30 minims as an expectorant; 1 to 3 
drams as an emetic. Sanguinarin, the alkaloid, 
unof. Dose, 1/12 to 1/8 grain; as an emetic, 1/2 
to 1 grain. 
SANOSE.-An albumin preparation, stated to 
consist of 80 percent of casein and 20 percent of 
albumose. It is a white, odorless, and tasteless 
powder, which readily forms emulsions with water. 
It is used as a food and tonic, preferably in form 
of emulsion. 
SANTALUM.-See Sandalwood. 
SANTONICA (Levant Wormseed).-The flower 
heads-of Artemisia pauciflora, the properties of 
which are due to a crystalline principle, santonin 
The flower heads yield about 2 percent of santonin, 
which is a very efficient anthelmintic against the 
round-worm, Ascaris lumbricoides. Dose, 1/4 to 2 
grains. The tape-worm is not affected by san- 
tonin. Santonin should be given, as are all 
vermifuges, with preceding catharsis and starva- 
tion. Sodium santoninate should not be used, 
as it is absorbed by the system rather than by the 
intestinal parasite. The crystals of santonin 
rather than the powder should be employed. A 
saline purge should be given, preferably followed 
in a half-hour by a 2- or 3-grain dose of calomel, 
if no bowel movement has occurred within 10 
hours after taking the santonin. 
I). Santonin, gr. v 
Powdered white sugar, 5 iij 
Powdered acacia, gr. viij. 
Mix well and add: 
Mucilage of acacia, gtt. xvj 
Water, sufficient 
quantity. 
Make into 10 troches. Give 1 or 2 as directed. 
See Anthelmintics. 
In large doses it produces yellow vision and 
gives a yellow color to the urine. In toxic doses 
it causes headache, vertigo, sometimes convul- 
sions, and death by respiratory paralysis. San- 
tonini, Troch., each contains 1/2 of a grain of the 
active principle. Dose, 1 to 5. 
SAPO.-See Soap. 
SAPREMIA.-See Sepsis. 
SARCINA.-A genus of Schizomycetes, or 
bacteria, having spheric or ovoid cells dividing in 
three directions, thus producing cubic masses of 
greater or less size. See Bacteriology. 
SARCOMA.-A connective-tissue tumor in 
which the cells so predominate in number, and 
often in size, that the intercellular substance 
becomes a secondary element. It may also be 
defined as a tumor made up of embryonal con- 
nective tissue. Sarcomata are malignant tumors, 
the small-celled forms and those of soft consistency 
excelling in this respect. They appear, as a rule, 
at an earlier age than carcinoma. The problem of 
their causation is not solved: in many instances it 
is possible to trace a history of injury. It is prob- 
able, however, that the trauma merely acts as a 
predisposing cause. To the naked eye sarcoma 
appears, as the etymology of the word indicates, 
flesh-like. Microscopically, the picture varies 
with the variety of tumor, whether it is a round- 
cell, a spindle-cell, or a giant-cell sarcoma, or one SARSAPARILLA 
SCABIES 
of the other derivative forms. Sarcomata are well 
supplied with blood, which, however, is not con- 
tained in true vessels, but in spaces lined by 
endothelium. They are often combined with 
other new growths, especially with the so-called 
mixed tumors and with certain congenital neo- 
plasms, as the rhabdomyoma. The most fre- 
quent seats of sarcoma are the connective tissue 
of the skin, periosteum, intermuscular septa, 
tendons, subserous connective tissue, and the eye. 
Treatment.-Operable growths should be early 
and thoroughly excised. Inoperable growths 
have been treated by inoculations with the strep- 
tococcus of erysipelas by reason of the fact that 
an attack of erysipelas sometimes has effected a 
cure. Recently a number of inoperable cases 
have been decidedly benefited by injections of 
Coley's fluid (a sterilized culture of the strepto- 
coccus of erysipelas and the bacillus prodigiosus). 
The initial dose is 1/2 minim injected into or 
around the tumor; the dose is gradually increased 
until there is a reaction of 101° to 103° F., then 
repeated every 2 to 3 days. If after 3 weeks 
no improvement results, treatment should be 
stopped. The X-rays have proved curative in a 
number of cases of sarcoma. See Carcinoma, 
Tumors, Bone (Diseases). 
SARSAPARILLA.-The dried root of Smilax 
medica, and several other species of the smilax 
family, native to tropical America. It contains 
an essential oil and several extractive principles, 
and is diuretic, tonic, and alterative. It has mild 
alterative properties and is a good vehicle for 
potassium iodid. It is used somewhat in tertiary 
syphilis, scrofula, and similar diseases. 
Preparations. Fluidextractum S.-Dose, 20 to 
60 minims. Fluidextractum S. Compositum has 
of sarsaparilla 75, glycyrrhiza 12, sassafras 10, 
mezereum 3, glycerin 10, diluted alcohol to 100. 
Dose, 20 to 60 minims. Syrupus S. Compositus 
has of the fluidextract 20, fluidextract of glycyr- 
rhiza 1 1/2, fluidextract of senna 1 1/2, sugar 65, 
oils of sassafras, anise and gaultheria, each 0.02, 
water to 100. Dose, 1 to 8 drams. 
SASSAFRAS.-The root bark of S. variifolium. 
Its properties are due to a volatile oil. It is 
aromatic and a stimulant diaphoretic. S. Oil, 
the volatile oil. Dose, 1 to 4 minims. Mucilago 
S. medullae. Dose, about 4 drams. 
SATURNISM.-See Lead (Poisoning). 
SAVINE (Sabina).-The tops of Juniperus 
sabina; its properties are mainly due to a volatile 
oil which resembles turpentine, but is more irri- 
tant. Dose, 5 to 10 grains. In large doses it 
produces violent purging and vomiting. It is 
used as an emmenagog. Externally, it is useful 
to prolong the discharge from blisters and to 
stimulate ulcers to cicatrization. S., Fluidextract. 
Dose, 2 to 10 minims. S., 01., the volatile oil. 
Dose, 1 to 2 minims. 
In amenorrhea: 
I|. Oil of savine, viij 
Mucilage of acacia, 5 j 
Camphor water, 3 iij. 
Two tablespoonfuls 3 times daily. 
SAW-PALMETTO.-See Sabal. 
SCABIES (Itch).-A contagious, animal, para- 
sitic disease due to the sarcoptes scabiei (acarus 
scabiei), characterized by burrows and a multi- 
form eruption, and attended by severe itching. 
Symptoms.-The itch-mite in burrowing into 
the skin produces at the point of entrance a small 
papule, vesicle, or pustule. Later, a burrow or 
cuniculus is formed at this site. The burrow is a 
straight, tortuous or zigzag, grayish or blackish, 
linear, epidermal elevation, varying in length 
from 1/8 to 1/2 inch. 
In a well-marked case of itch there may be seen, 
in addition to the burrows, a multiform eruption 
consisting of papules, vesicles, pustules, crusts, 
excoriations (scratch marks), and thickening, 
occupying certain definite regions where the skin 
is thin; these are the interdigital spaces, the flexor 
surface of the wrist and arm, the anterior and 
posterior axillary folds, the breasts and nipples 
(in women), the umbilicus, the buttocks, the penis, 
the inner side of the thighs and legs, and the toes 
(particularly in infants). The face is exempt 
except occasionally in infants. 
The eruption is attended by intense itching, 
which is distinctly worse at night. The irre- 
sistible scratching leads to the production of the 
secondary inflammatory symptoms. In children 
and individuals with sensitive skin the eruption 
may reach a high grade of inflammation. In 
predisposed subjects an eczema may be super- 
added to the scabies. The disease develops rapid- 
ly in the course of from 1 to 2 weeks. It is pro- 
gressive, exhibiting no tendency to spontaneous 
cure. In untreated cases it may last many months. 
Etiology.-The disease is due to the invasion of 
the skin by the sarcoptes or acarus scabiei. It is 
highly contagious. The 
disease may be trans- 
mitted by direct bodily 
contact or through the 
intermediation of such 
articles as the bedclothes. 
It occurs at any age, and 
is particularly common 
among the lower classes. 
Pathology.-The bur- 
row consists of a narrow 
tract through the epidermis made by the pene- 
tration of the impregnated female acarus. The 
mite deposits a half dozen or more eggs and 
specks of excrement along the course of the tract, 
and, after reaching the mucous layer, perishes. 
The ova hatch out in 8 or 10 days and, effecting 
their egress from the burrow, start cuniculi of 
their own. The itch-mite is a yellowish-white 
ovoid body, just visible to the eye. The female is 
twice the size of the male. 
Diagnosis.-Scabies consists of the burrows 
plus an artificial inflammation of the skin, produced 
by the parasite and by the scratching. The char- 
acteristic features of the disease are the presence 
of the burrows, a multiform eruption distributed 
in a peculiar manner over the surface of the body, 
the intense itching-worse at night-and the 
history. 
Sabcoptes Scabiei. A. Male. 
B. Female.-(Braun.) SCALDS 
Scabies may be distinguished from vesicular 
or pustular eczema by the presence of the mite and 
the burrows, the peculiar distribution of the le- 
sions, the progression of the eruption from day to 
day, and the history of contagion. From pedic- 
ulosis corporis the disease may be differentiated 
by the character of the eruption and the regions 
affected. 
Prognosis is favorable. The disease, no matter 
of what duration, is speedily curable. 
Treatment.-The objects of treatment are two- 
fold-to kill the parasite and to subdue the ac- 
companying dermatitis. The itch-mite is easily 
destroyed by such remedies as sulphur, beta-naph- 
thol, balsam of Peru, styrax, tar, staphisagria, etc. 
Sulphur is one of the most reliable remedies, and 
is best applied in ointment form. It may be 
used in conjunction with balsam of Peru, as in 
the following formula: 
For adults or those of nonirritable skin: 
I|. Precipitated sulphur, 3 j 
Balsam of Peru, 3 ss 
Beta-naphthol, 3 ij 
Lard, 1 . 
Petrolatum, j eac ' $ 1V* 
Make into an ointment. 
Beta-naphthol possesses the advantage of being 
free from odor and more cleanly. It may be 
used alone (1 dram to 1 ounce) or combined with 
sulphur. 
Styrax is less irritating than sulphur, and is 
useful in the itch of children: 
I). Styrax, 3 ss 
Lard, 5 jss. 
The treatment should be inaugurated by a 
protracted hot bath, with the vigorous use of 
soap. The body from neck to feet is then to be 
thoroughly smeared with the ointment. This 
may be rubbed in twice a day for 3 days, or 
nightly for 1 week. At the end of this time 
another bath should be taken, and the under- 
clothing and bed-linen changed and sterilized. 
Ordinarily, such treatment will suffice to produce 
a cure; occasionally, it must be repeated. 
Care should be exercised not to overtreat cases. 
The persistence of itching is not always an index 
of the continuance of the scabies, but is more 
likely to result from the dermatitis, which is, 
perhaps, aggravated by the parasiticide applica- 
tion. In such a case a sedative ointment or lotion 
should be substituted. 
SCALDS.-See Burns. 
SCALP, DISEASES.-Abscess may occur above 
the aponeurosis, between the aponeurosis and the 
pericranium, or beneath the pericranium. It is 
generally the result of an injury, but may be due 
to the breaking down of a gumma, diseases of the 
bones, etc. 
Cellulitis of the scalp is usually due to a wound, 
and is described under Scalp (Injuries) (q. v.). 
Erysipelas of the scalp is common, and may occur 
idiopathically or as the result of a wound. In the 
so-called idiopathic cases, however, it is probable 
that there is generally some scratch or abrasion 
SCALP, INJURIES 
through which the specific micrococcus gains ad- 
mission. The inflammation spreads with great 
rapidity, but is accompanied by very little redness 
and swelling on account of the tenseness of the 
parts. It is likely to be attended with headache, 
drowsiness, or delirium, consequent upon the 
hyperemia extending to the pia mater. See 
Erysipelas. 
Naevi are also common on the scalp. When large 
and situated over the anterior fontanel, they should 
be dealt with cautiously, lest the membranes of 
the brain are injured and meningitis results. 
Rodent ulcer and epithelioma of the scalp require 
no special mention here. 
Sebaceous cysts are very common on the scalp, 
where they are at times hereditary. They are 
frequently multiple, and as they increase in size 
the hair covering them falls off, and they appear as 
bare, rounded tumors. The mass of granulations 
which sometimes protrudes from the walls of these 
cysts (fungating ulcer of the scalp) closely resembles 
epithelioma, from which, however, it may gener- 
ally be distinguished by the absence of induration 
and glandular enlargement, and by the history of 
a sebaceous cyst having been previously present. 
Congenital and dermoid cysts are met with. 
Seborrhea.-See Alopecia, Seborrhea. 
SCALP, INJURIES.-The scalp presents certain 
anatomic features of considerable surgical im- 
portance. The skin in the first place is so closely 
bound down to the aponeurosis beneath that mere 
cutaneous wounds never gape, and superficial in- 
flammation is never attended by much swelling 
or redness. For the same reason contusions often 
cause what apparently are incised wounds. 
Further, the chief vessels lie between the aponeuro- 
sis and the skin, and are embedded in such dense 
tissue that when they are cut they cannot retract, 
and can hardly be tied. On the other hand, 
beneath the aponeurosis the tissue is so loose that 
blood or pus may collect until the skin floats as on 
a water-bed, bounded by the zygoma, the eye- 
brows, and the superior curved line; and the scalp 
can be stripped off and hang in flaps. Sloughing, 
however, owing to the position of the vessels, is 
rarely caused in this way. Finally, the peri- 
cranium is easily separated from the bone, except 
at the sutures; it only supplies the outer table, not 
the diploe or the inner, so that when necrosis 
occurs from this cause, the sequestrum is usually 
superficial. It is peculiar also that it seldom 
produces any new bone to repair an injury. 
Contusions.-The blood may be extravasated 
(1) in the scalp itself; (2) in the subaponeurotic 
layer, or (3) between the pericranium and the 
bone. 
The first, owing to the denseness of the tissue, is 
always insignificant. The second may be either 
diffuse and of enormous extent, or circumscribed, 
and then very often it is curiously deceptive. The 
blood around the margin coagulates into a hard, 
dense ring, the inner edge of which is sharp and 
well defined, while the outer is beveled off; in the 
center it remains fluid, so that when the finger is 
pressed upon it the margin stands out as clearly 
as the edge of a depressed fracture, for which it SCALP, INJURIES 
SCAPULA, FRACTURES 
may easily be mistaken. The ring, however, is 
distinctly raised above the level of the surrounding 
bone, and it can always be indented. Abscesses 
sometimes give rise to the same kind of impression, 
and it must be remembered that the presence of a 
hematoma does not exclude the existence of a 
fracture. 
The third (cephalhematoma) only occurs in 
infants, and nearly always from injuries received 
at birth. It is most common on the parietal bone 
-though it has been seen on the occipital-and 
is easily recognized by the way in which it is 
limited to one bone; it never extends over the 
sutures. Like the former, the margin becomes 
hard, and a certain amount of organization, and 
even ossification, takes place; the center remains 
fluid, and for a long time gives rise to a sensation 
of parchment crackling when pressed upon. Ab- 
sorption in all these cases is slow; but, unless in- 
flammation sets in, they should never be incised, 
and aspiration is rarely necessary. The cephal- 
hematoma of infants should not be operated upon; 
in other cases lead lotion may be applied at first, 
or, if the patient will lie down, an ice-bag, to check 
the extravasation and hyperemia; afterward, well- 
applied pressure is the most efficient remedy. 
Wounds.-These, like contusions, may be 
superficial, involving the skin only; or extend into 
the subaponeurotic layer; or lay the bone bare. 
The first are rarely of any extent; in the second, 
if the hair is entangled in machinery, or the head 
caught under a cartwheel, the whole scalp may be 
detached and hang down in a flap, but it rarely 
sloughs; in the third, there is an additional danger, 
for the bone is exposed, and is often bruised or 
scratched. Hemorrhage from the torn vessels 
is often abundant, but neither ligation nor torsion 
is of any use. Pressure stops it at once. Acu- 
pressure may be used, but a bandage is nearly 
always sufficient; care, however, is necessary, as 
it may be applied so tightly as to cause a slough. 
Treatment.-Scalp wounds require no special 
treatment: the same principles must be followed 
as elsewhere; the only peculiarities are the extra- 
ordinary vitality of the skin, and the ease with 
which inflammation, if it once occurs, spreads in 
all directions. Therefore no portion of the scalp 
should ever be sacrificed, no matter how bruised 
or dirty it is; and perfect cleanliness and perfect 
drainage must be insisted on. If this is carried out, 
they may be treated like other wounds, and with 
exceptional success. 
The head must be shaved about the injury, the 
wound carefully explored, washed out thoroughly 
with an antiseptic, all oozing stopped, and any 
bagging or collecting of fluid prevented. Counter- 
openings may be made and drainage-tubes inserted, 
if there is a dependent pouch; but in most cases 
it is sufficient to support the skin well against the 
skull so as to keep it at rest and insure early ad- 
hesion. Then the edges of the wound may be 
dusted over with iodoform and covered with an 
absorbent dressing, such as wood-wool, or a 
sponge wrung out of carbolic solution. There is 
no objection to the use of sutures, if care is taken; 
but if the wound is tightly sewed up, and suppura- 
tion allowed to take place beneath, serious con- 
sequences must ensue. Ev.en if half the scalp is 
stripped off and hangs down the back of the neck, 
or over the face, it may be treated in this way, and 
often will adhere at once. If it does not, the under 
surface throws out granulations and union takes 
place by the third intention. In all cases of severe 
injury the patient should be confined to bed, and 
kept perfectly quiet, on low diet; and care must 
be taken that the bowels do not become consti- 
pated. It must never be forgotten that, in 
addition to the scalp wound, there may be very 
great injury to the brain. 
So long as there is no pain nor fever, the wound 
should be left alone. If, however, one spot is 
tender, or if the temperature rises, or if there is 
any shivering, the wound must be exposed at 
once and carefully examined; it nearly always 
means that some of the secretion is pent up. As 
a rule, it is sufficient to introduce a probe or to 
loosen a suture- a drop or two of fluid escapes, 
and the symptoms are relieved at once (Moullin). 
SCAMMONY.-A purgative gum-resin, the dried 
juice of the root of Convolvulus scammonia, a 
Southwestern Asiatic plant. It is generally given 
in combination with other drugs. Its properties 
are due to an active principle, jalapin. It is a 
drastic cathartic, and is contraindicated when 
there is a tendency to true inflammation of the 
bowels. It is anthelmintic against the tapeworm, 
and in overdoses produces a high degree of irrita- 
tion. It is used as a drastic purgative for children 
with calomel or potassium sulphate. Treatment 
suitable for gastroenteritis may be necessary if 
poisonous doses have been administered. It is best 
given with colocynth or some similar drug. Dose, 
1 to 10 grains. S., Resina. Dose, 1 to 5 grains. 
SCAPULA, CONGENITAL ELEVATION OF.- 
See Sprengel's Shoulder. 
SCAPULA, DISLOCATION.-The acromion may 
be dislocated from the scapula upward or downward. 
The conoid and the trapezoid ligaments are strong 
enough to make both injuries unusual, and the 
former very rare. A fall or blow is the most com- 
mon cause; carrying heavy weights may be causa- 
tive. This dislocation is easy to reduce, but very 
difficult to keep in place. Drawing the shoulder 
back and pressing the clavicle down will restore the 
joint, but the deformity recurs on removal of 
pressure. Velpeau's dextrin band and Holland 
plaster are the most successful methods of treating 
this dislocation. Sloughing of the skin is to be 
carefully looked for. A pad over the acromial end 
of the clavicle may be strapped down by means of 
a broad webbing band carried over it and under 
the point of the elbow. When the deformity is 
the first consideration, the patient should be 
placed perfectly flat on the back for a week or 
10 days, the scapula fixed, the weight of the limb 
taken off, and the trapezius relaxed. See Shoul- 
der (Dislocation). 
SCAPULA, FRACTURES.-The scapula is so 
much covered with muscle, and its connections 
with the trunk allow so much yielding on the 
application of external force, that fractures of 
this bone are extremely uncommon. SCARIFICATION 
SCARLET FEVER 
Varieties.-The injury may occur to its body, its 
inferior angle, its neck, to the acromion process, or 
to the coracoid process. 
Symptoms.-In fracture of the body of the bone 
the shoulder will be depressed and forced forward, 
and there will be marked irregularity between the 
ends of the fragments. Fracture of the inferior 
angle is marked by preternatural mobility, by dis- 
placement of the smaller fragment, and by acute 
pain at the seat of inj ury. In fracture of the neck 
the acromion is unusually prominent, the head of 
the humerus is felt in the axilla, the shoulder is flat- 
tened, the limb is lengthened, the coracoid process 
is found below the clavicle, severe pain and numb- 
ness are experienced in the axilla, and distinct crep- 
itation is perceived on rotating the arm upon the 
scapula. In fractures of the acromion and of the 
coracoid the symptoms are somewhat similar to 
those presented by the fracture of the neck. 
Treatment.-When the body is broken, a broad 
roller must be passed around the trunk, over a 
large flat pad placed over the scapula, and a few 
turns made around the arm so as to fix it to the side 
and prevent motion. Rest and quietude are 
required. Or a broad strip of adhesive plaster 
should be applied across the scapula, extending 
from the spine to the sternum, care being taken to 
press it well down along the anterior and posterior 
borders of the bone before the portions in front and 
behind the chest have been attached. Then place 
the arm in a Fox apparatus, and allow it to hang 
vertically along the side of the body, at the same 
time lifting the elbow by securing the straps to the 
ring on the opposite shoulder. 
In fracture of the neck the shoulder must be sup- 
ported by the sling and bandage that are used for 
fracture of the clavicle; but the pad should not be 
so thick, nor so large, and in addition a short sling 
should be used, going from the axillary pad on the 
injured side to the opposite shoulder. Opium, 
rest, leeches, and purgatives may be necessary for 
the contusion with which this fracture is accom- 
panied. At the end of 4 weeks passive motion must 
be made to establish the functions of the joint. 
In fracture of the acromion the bandages are to 
be applied so as to raise the elbow thoroughly, so 
that the head of the humerus may be lifted up 
against the acromion and keep its place. A pad 
must not be placed in the axilla, otherwise the 
broken part will be pushed outward too much. 
When the coracoid process is fractured, the 
humerus must be brought forward and inward, so 
as to relax the coracobrachialis, and must be con- 
fined to the trunk, with the forearm bent on the 
chest. 
SCARIFICATION.-The operation of making 
superficial incisions or punctures to allow the 
escape of serum or blood or gases. According to 
circumstances they may be deep or penetrate 
through the skin alone. In conjunctival chemosis, 
in early acute tonsillitis, in edema or engorgement 
of the glottis, and in congestions and certain 
acute inflammations of the uterus, in inflamed 
ulcers, and those in danger of gangrene, and, 
indeed, in almost any condition of great tension, 
the procedure will give relief. 
SCARLET FEVER (Scarlatina).-An acute 
infectious disease, characterized by sudden onset, 
with vomiting, high fever, sore throat, and an 
erythematous rash. Serious complications and 
sequels are not uncommon. It is contagious from 
the beginning of the attack until desquamation has 
ceased, and under certain conditions after this 
time. One attack is rarely followed by subse- 
quent ones. 
Etiology.-While believed to be due to a micro- 
organism, none has as yet been demonstrated as 
the specific one. Streptococci have been found 
in the blood by many observers, and less fre- 
quently the staphylococcus aureus and the 
influenza bacillus, but these are probably present 
as a result of mixed infection. Scarlet fever 
occurs epidemically, and occasionally sporadic- 
ally, the epidemics being most common in the 
fall and winter. As it is most contagious late in 
the disease (during desquamation), epidemics 
spread slowly. 
The skin seems to be the chief source of infection, 
but it may be conveyed by the discharges from 
the mucous membrane of the nose, mouth, or 
throat, and by the urine, feces, or perspiration, 
and later, even after desquamation has ceased, by 
purulent discharges from rhinitis, otitis, suppurat- 
ing glands, etc. The carpet and furniture of the 
sick room, and toys, books, and clothing, which 
may have been in contact with the patient, are often 
a medium of contagion, as may also be the attend- 
ants or nurses. Air may convey the infection for a 
short distance, and the usual route of infection is 
the respiratory tract. It may, however, enter 
by way of the digestive tract. Domestic animals 
may transmit the disease, and it has, in a number 
of cases, been spread by food-particularly milk. 
Children are much more susceptible than adults, 
but in either the susceptibility to scarlatinal infec- 
tion is much less than to that of measles. 
Pathology.-The parts primarily affected are the 
throat and skin. Lesions of other organs are rare, 
but, when present, are due to the fever and septic 
condition. The principal pathologic lesions due 
to complications are of the ear and cervical glands; 
the chief ones from sequels are those of the kidneys 
and heart. 
The scarlatinal throat consists of an erythemat- 
ous condition of the mucous membrane with the 
usual changes of a catarrhal inflammation. The 
skin is hyperemic, inflamed, and swollen, causing 
death of the epidermis, which is cast off during 
desquamation. 
Symptoms.-The period of incubation is short 
-1 to 5 days-during which time there are no 
symptoms to indicate the onset of a disease. 
The invasion is sudden: the first symptom in 
the majority of cases being vomiting. The child 
complains of chilliness, headache, and sore throat. 
The temperature will be high from the first (103° 
to 104° F.) and the pulse rapid and wiry. Pros- 
tration is usually well marked, and there may be 
slight delirium, and, in young children, convul- 
sions. The skin is hot and dry, the face flushed, 
and the eyes bright. 
On inspecting the throat, the tonsils, pharynx, SCARLET FEVER 
SCARLET FEVER 
and fauces will be found red and congested, and 
there will be seen on the hard and the soft palate 
minute macules of a darker red color than the 
intervening mucous membrane. An exudate 
resembling follicular tonsillitis, or even the mem- 
brane of diphtheria, may appear upon the tonsils. 
At the end of from 12 to 36 hours after the 
onset the efflorescence appears, and in most cases 
is first seen upon the front of the neck and the 
upper part of the chest, but rapidly extends all 
over the body and face, being fully developed in 
the course of from 12 to 24 hours. The rash is of 
a bright scarlet color, and when viewed at a short 
distance, the whole surface of the body appears 
to be uniformly covered; but examined closely, 
it consists of great numbers of red points corre- 
sponding with the hair follicles; these points are 
surrounded by zones of erythematous redness, 
which, joining one another, give the general 
diffuse red appearance to the skin. 
In some cases the rash consists of the points 
only, without the erythema; in others it may 
appear in patches with normal skin between. 
Rather rarely the rash is hemorrhagic, small 
extravasations of blood taking place into the 
skin; this may occur in mild, but is much more 
common in malignant, cases. With the eruption 
at its height there is intense itching or burning of 
the skin, and often considerable swelling, which 
is most noticeable upon the hands and face. The 
eruption remains at its maximum intensity for 
about 3 days and then fades in the order in which 
it appeared. 
The temperature, which has remained high 
from the first, gradually declines after about the 
fourth day, or as the rash begins to fade, reach- 
ing the normal in 5 or 6 days. The tongue, 
which for the first few days was covered with a 
thick white fur, as the disease progresses becomes 
reddened with enlarged and prominent papillae, 
the appearance giving rise to the name "straw- 
berry tongue." The lymphatic glands at the 
angle of the jaw are usually enlarged and tender. 
The constitutional symptoms during the erup- 
tive period are marked by loss of appetite, con- 
stant thirst, somnolence with delirium or restless- 
ness, with more or less nervous manifestations. 
The bowels may be either constipated or loose; 
the urine scanty, high-colored, and often con- 
taining albumin. Not infrequently the urine and 
stools are passed involuntarily. The respiratory 
tract is not often affected, though there may be a 
mucous discharge from the nose and in some cases 
a dry cough, due to the irritation in the throat. 
With the fading of the rash and the decline in the 
temperature the tongue clears, the throat becomes 
less congested, and the appetite improves; and, 
by the end of the first week, convalescence should 
be established; feverishness after this time would 
suggest some complication, as suppurating glands, 
purulent otitis, etc. 
Desquamation begins soon after the rash fades 
-about the seventh day-and continues for a 
period of 2 to 5 weeks. It is usually first seen 
upon the chest and neck, and is composed of very 
fine scales. Desquamation upon the face is 
usually slight, or it may not occur at all. That 
which follows on other parts of the body, espe- 
cially where the skin is thick and hard-as upon 
the inside of the fingers and hands and the soles 
of the feet-is composed of large scales, and a 
cast of the part may be thrown off like the finger 
of a glove. The hair, nails, and teeth are usually 
also affected. The hair breaks off after scarlet 
fever; the nails show indentations, and some- 
times are shed; and the forming teeth are more or 
less affected. 
. While the foregoing description is that of a 
typical form of scarlet fever, in practice many 
cases are seen which vary from the mild form- 
when the child may make no complaint of being 
ill, the rash, and that often not well marked, 
being the first symptom-to the malignant form, 
when the onset is severe, with marked nervous 
symptoms, high fever, very rapid pulse, diarrhea, 
and marked glandular swelling and cellulitis, 
the child dying during the first 24 hours, or 
lingering for 2 or 3 weeks, when death results 
from exhaustion or from septicemia. 
Complications and Sequels.-The inflammation 
of the throat may be so severe as to constitute a 
serious complication. The soft palate may slough, 
and all the soft parts be destroyed. The inflam- 
mation may spread to the larynx, making, in 
some cases, tracheotomy necessary. Purulent 
otitis media is a common complication, and is 
caused by extension of infection through the 
eustachian tubes. It may occur either during or 
following the active stage, and it is the most 
frequent cause of continued fever after the rash 
has disappeared. 
Following severe cases, adenitis may occur, 
often accompanied by suppuration and ulceration 
of the cervical lymph-glands; cellulitis of the neck 
may occur. Septic cases may be complicated by 
bronchopneumonia or pleurisy, and also by 
endocarditis and myocarditis. 
Arthritis, septic, rheumatic, or tubercular, some- 
times occurs with or following scarlet fever. 
Rarely nervous affections may arise as com- 
plications, such as meningitis, chorea, hemiplegia, 
convulsions, progressive paralysis. 
Nephritis is the most frequent complication, and 
may occur in an otherwise mild and favorable 
case. Besides the transient albuminuria, which 
is nearly always present during the febrile stage, 
two forms-septic and post-scarlatinal nephritis- 
occur. The septic form occurs in severe cases 
complicated by sloughing tonsils and soft palate 
and much glandular involvement. The urine con- 
tains large quantities of albumin, and, postmortem, 
a pyemic kidney may be found, but dropsy or 
other renal symptoms are seldom discovered. 
Postscarlatinal nephritis occurs during the 
third or fourth week. The child, who had re- 
covered from the fever, will again become feverish, 
restless, and thirsty, have a quick hard pulse, and 
pass small quantities of dark-colored urine con- 
taining albumin and casts. The face becomes 
pale and puffy, and there may be edema of the 
feet and scrotum or general dropsy. 
In mild cases by the end of a week improvement SCARLET FEVER 
SCARLET FEVER 
will take place, and the child go on to recovery. 
In others, however, uremic symptoms may su- 
pervene, the pulse becomes slow, the temperature 
subnormal, and vomiting and marked nervous 
symptoms appear. Dilatation of the heart is a 
frequent result of the kidney affection. Recovery 
takes place in the great majority of the cases of 
nephritis following scarlet fever, but it may be 
prolonged for weeks or, rarely, for months. 
Diagnosis.-The diagnosis of the usual type is 
not difficult-the symptoms mentioned above all 
occurring together in no other disease. In some 
cases, however, the rash may appear not unlike 
measles; in others, the throat symptoms being 
prominent may lead to a diagnosis of diphtheria; 
but in a great majority of cases a mistake is not 
probable. However, there may be no distinctive 
eruption, but close watching will sometimes 
detect signs of desquamation in the shape of 
branny scales beneath the underclothing or in the 
stockings. In other doubtful cases the develop- 
ment of nephritis settles the diagnosis. 
The following table gives the principal points 
of difference between these diseases: 
Scarlet Fever. 
Measles. 
Diphtheria. 
Onset 
Sudden, with vomiting 
Gradual, with coryza and 
photophobia. 
High, but drops with appear- 
ance of rash. 
Not involved 
Gradual. 
Temperature 
High (103° to 105° F.) 
Low. 
Cervical glands 
Involved, usually 
Involved. 
Appearance of throat... 
False membrane 
Mucous membrane of hard and soft pal- 
ates much congested and red eruption 
first seen there. 
When present, resembles follicular tonsil- 
litis. 
Probably find streptococci 
Throat not involved 
Dusky red color early 
Characteristic. 
None 
Bacteriologic test 
Negative 
Klebs-Loeffler bacillus. 
Pulse 
Very rapid and wiry 
Full and bounding 
Increased, but weak. 
Albumin. 
Urine 
Frequently slight albumin 
No albumin 
Rash 
Scarlet color, first seen on neck and chest, 
appears within 36 hours after onset. 
Marked, beginning furfuraceous, becomes 
lamellar, continues 3 or 4 weeks. 
Darker color, first on face; 
appears fourth day. 
Slight, furfuraceous 
None typical. 
None. 
Desquamation 
Certain drugs, as belladonna, quinin, and antipy- 
rin, and digestive disturbances, especially in in- 
fants, are often accompanied by a rash, which 
closely resembles that of scarlet fever. It is, 
however, of short duration. In diphtheria, in- 
fluenza, and varicella an erythematous rash is 
occasionally seen that may cause them to be mis- 
taken for scarlet fever; but when the history of 
the case, the order of the appearance of the rash, 
etc., are considered, a correct diagnosis may in 
most cases be reached. 
Prognosis.-The prognosis should be guarded in 
all cases of young children. The mortality varies 
greatly in different epidemics, and may be as low 
as 5 or 6 percent, or as high as 20 or 30 percent, 
and in very young children as high as 50 percent. 
It depends generally upon, first, the severity of 
the epidemic; second, the age and resisting power 
of the individual; and, third, upon the nature of 
the complications. In no disease is the prognosis 
more uncertain than in scarlatina. 
Treatment.-The patient should be isolated for 
a period of 5 or 6 weeks, or until desquamation 
is completed. Should there exist such complica- 
tions as otitis, rhinitis, or suppurating glands, 
quarantine should be continued until these con- 
ditions are cured. Other children in the house 
who have not been exposed to the disease should 
be sent away. 
After recovery, the patient should, before 
mingling with others, be thoroughly scrubbed 
with soap and warm water and washed with an 
antiseptic solution-e. g., bichlorid of mercury, 
1:5000-and dressed in clean clothing. The 
sick room should be on the upper floor; it should 
be well ventilated, and kept at a uniform tempera- 
ture of about 68° F. The ideal method of heating 
is by an open-grate fire. 
The room should be stripped of all hangings, 
carpets, and unnecessary furniture, and a sheet 
wet with a solution of carbolic acid, 1:100, or 
bichlorid of mercury, 1:1000, kept hung over 
the doorway, and the floor frequently sprinkled 
with the same solution. All excreta from the 
patient should be disinfected by carbolic acid, 
1:20. The nurse should wear a cap covering 
the hair, and a washable dress, and should not 
mingle with other members of the family until 
her hands and face are thoroughly cleansed and 
her clothing changed. 
The same care should be given to the disin- 
fection of all bed-clothing, cloths, eating utensils, 
etc., as in diphtheria. The physician before 
entering the sick room should remove his coat and 
put on a long gown or rubber coat, and after the 
visit his hands, face, and hair should be washed and 
disinfected. 
If it can be avoided, the physician attending 
a scarlet fever patient should not attend an 
obstetric case or other patients with open wounds. 
When this is impossible, however, he should use 
the greatest care in disinfecting himself. 
Children should be kept in bed for at least a 
week after the fever has subsided, and on a liquid 
diet for 2 weeks longer, as this is important in 
preventing nephritis. Plenty of water should 
be given to drink, and the addition of 10 or 15 
drops of dilute muriatic acid to the glass of water 
will often prove grateful to the patient. 
Systematic bathing and inunctions should from SCARLET FEVER 
SCHISTOSOMIASIS 
the first be insisted upon, as this reduces the 
fever and restlessness, keeps the skin active, 
shortens the course, and prevents complications. 
The patient should be thoroughly sponged all 
over daily, or when the temperature is high 
every few hours, with carbolized water (1:100) 
or bichlorid of mercury (1:8000), or, if preferred, 
salt water, or alcohol and water. The tempera- 
ture of the water should be from 70° to 100° F., 
according to the amount of fever present, using 
the cooler baths when the temperature is high. 
Following the sponging there should be applied 
all over the body cacao-butter, lanolin, or cosmolin, 
to which may be added 10 grains to the ounce of 
menthol, or the following: 
When there is constipation, small doses of calo- 
mel should be given to act upon the bowels, and 
when, as sometimes occurs, diarrhea is trouble- 
some, one of the bismuth mixtures mentioned 
under diarrhea of infants and children should be 
given. 
The vomiting that was present at the onset 
seldom persists after the first 24 hours; should it 
do so, however, small bits of ice should be given 
to swallow every 5 or 10 minutes, and camphor- 
ated tincture of opium, in 1- to 5-drop doses every 
2 or 3 hours, or cocain, 1/20 grain. Food should 
be withheld while there is any vomiting. 
For the nervous symptoms may be given phen- 
acetin or acetanilid (1/2 grain for each year of a 
child's age), repeated in 3 or 4 hours if necessary. 
To this should be added 1/2 to 1 grain of quinin 
to each dose, if the child will take a capsule. 
A very weak or irregular pulse or cyanosis calls 
for stimulants: aromatic spirit of ammonia, 10 
drops in water, or brandy or whisky, 10 drops to a 
teaspoonful according to the child's age; as soon 
as the urgent symptoms are relieved, discon- 
tinue the use of the alcohol, however, owing to 
its action upon the kidneys. 
A useful heart stimulant for these cases is the 
following: 
1$. Carbolic acid, gr. v 
Menthol, 
Thymol, 
each, gr. x 
The inunctions are agreeable to the patient, 
relieve the itching and burning, prevent the scales 
from becoming disseminated through the air, 
and at the same time protect the surface and 
render joint involvement less likely to occur. 
The bathing and inunctions should be continued 
as long as desquamation exists. 
The hygiene and proper treatment of the nose 
and mouth is also very important, tending to 
prevent ear complications. The throat should 
be sprayed or gargled with an alkaline or anti- 
septic solution 3 or 4 times a day. For this pur- 
pose may be used a solution of bicarbonate of 
sodium (20 grains to the ounce), a solution of lis- 
terine, one of the various modifications of Dobell's 
solution, or- 
Lanolin, 3 j. 
1$. Camphor water, 
Tincture of musk, 
From 1/2 to 1 teaspoonful in water every 
2 hours. 
Strychnin (in doses of 1/100 to 1/30 grain 
according to the age of the patient) or nitro- 
glycerin (in doses of 1/500 to 1/100 grain) are 
also very useful. 
The prevention of complications is of para- 
mount importance. The drum membrane should 
be watched for signs of bulging and if found, 
paracentesis should not be delayed. The urine 
should be examined daily for the onset of nephritis; 
in order to prevent this complication the patient 
should be shielded from drafts and kept on liquid 
diet in bed at least a week after the cessation 
of febrile symptoms. Urotropin is recommended 
as a prophylactic remedy. 
By the careful hygienic treatment of the nose 
and throat, and by the baths and inunctions, 
complications will be much less frequent, but 
when they do arise, the treatment is the same as 
for similar conditions when occurring independ- 
ently of scarlet fever. 
During convalescence iron, cod-liver oil, and 
general tonic treatment are indicated. 
Serum Therapy.-Injections of antistrepto- 
coccic serum instituted early in the disease in 
doses of 20 c.c. have proved markedly valuable 
for the relief of the complications that occur so 
frequently as a result of streptococcic infection. 
SCHISTOSOMIASIS (Bilharziosis).-A chronic 
parasitic, tropical disease, characterized by 
hematuria, cystitis, proctitis, due to the eggs of 
the blood fluke, distomum or schistosomum 
hematobium. Lesions due to the parasites are 
found in the kidneys, urethra, bladder, liver, 
rectum. The ova of the worm are easily detected 
each, 3 j. 
1$. Hydrogen dioxid, 
Glycerin, 
each, 3 j 
Water, 3 iij. 
To a young child who cannot gargle the follow- 
ing may be given: 
3. Boric acid, gr. xx 
Salicylic acid, gr. xxx 
Peppermint water, 3 j 
Water, 3 iij. 
One teaspoonful every 2 hours until the 
throat symptoms are relieved. 
Or- 
3- Tincture of iron chlorid, 3 ij 
Glycerin, 3 j 
Water, 3 iij. 
One teaspoonful every 3 or 4 hours. 
The nose should be sprayed 2 or 3 times a day 
with a mild alkaline solution, and an oily sub- 
stance applied to the anterior and posterior nares 
by means of cotton on a match-stick or probe. 
For this purpose may be used 5 or 10 grains of 
menthol in an ounce of liquid albolin. Cold 
compresses or ice applied to the throat externally 
is very soothing. If the throat symptoms are 
severe, adrenalin chlorid sprays may be used as 
well as inhalations of steam impregnated with 
oil of eucalyptus or compound tincture of benzoin. SCHLEICH'S INFILTRATION ANESTHESIA 
SCIATICA 
by microscopic examination of the urine and 
feces. The parasite probably gains entrance to 
man through drinking or bathing in or working 
with infected water, or with some mollusc, fish 
or vegetable. Treatment is merely prophylactic 
and palliative. 
Schistosomum Japonicum resembles the S. 
hematobium, but is smaller and the eggs have no 
spines. This infection is characterized by en- 
largement of liver, spleen and mesenteric lymph 
glands, anemia, diarrhea, enteritis. The eggs, 
which resemble those of ankylostomum duoden- 
ale, are found not in the urine but in the feces. 
SCHLEICH'S INFILTRATION ANESTHESIA.- 
See Infiltration Anesthesia. 
SCHLEICH'S MIXTURE (for General Anes- 
thesia).-See Anesthetics. 
SCHOTT TREATMENT.-The Schott method 
may be stated briefly as consisting of the sys- 
tematic use of saline baths of definite strength 
and temperature, and the coincident or alterna- 
tive employment of a certain series of resisted 
movements. The treatment originated in Nau- 
heim, Germany, where the natural springs are 
strongly saline and heavily charged with carbonic 
acid gas, their varying temperature and strength 
making them admirably adapted to therapeutic 
use. The most important chemic constituents of 
these baths are sodium chlorid (1 to 3 percent), 
calcium chlorid (0.1 to 0.3 percent), with a con- 
siderable quantity of iron, and a large amount of 
free carbonic acid gas. Their temperature varies 
from 81.7° to 95.5° F. In practice the higher 
temperature and weaker waters are first used, 
the waters being freed from the carbonic acid gas; 
a lower temperature, effervescent bath, and greater 
strength in saline constituents being gradually 
attained as the treatment progresses. Baths are 
given daily, rarely more than 3 being taken con- 
secutively, that of the third or fourth day being 
omitted. While the natural baths are better 
adapted to treatment, perfectly satisfactory 
results may be obtained from artificial baths made 
after the following: 
Formulas.-To 40 gallons of water (usual 
amount required) add sea-salt, 3 to 10 pints 
(approximate strength 1 to 3 percent); calcium 
chlorid, pure, 11 to 15 ounces. It is important to 
note that this latter ingredient is not the com- 
mercial chlorid of lime, which, by giving off 
chlorin, would become a source of discomfort and 
danger. To introduce or generate carbonic acid 
gas we may use a soda siphon with conducting 
tube or the following formulas of Bezley Thorne: 
Mild.-NaHCO3, 1/2 pound; HC1 (25 percent), 
3/4 pound. 
Medium.-NaHC03, 1 pound; HC1 (25 percent), 
11/2 pounds. 
Strong.-NaHCO3, 2 pounds; HC1 (25 percent), 
3 pounds. 
The salts are first dissolved; the hydrochloric 
acid is then added and thoroughly distributed. 
It has been found that the best agent for adding 
the acid is a douche bottle and tube, the acid 
being thus evenly distributed throughout the 
mixture. 
Immersion.-The patient remains immersed 
from 5 to 20 minutes, the first bath being brief 
and the period gradually lengthened. If the 
patient is very ill, he should be carried to and from 
the bath and spared any exertion. While in the 
bath he should remain absolutely quiet, breathe 
regularly, and refrain even from speaking. Upon 
leaving the bath he may be rolled in warm blan- 
kets, to rest for at least one hour. 
Temperature.-The temperature is at first about 
93° F., and may be considerably reduced after the 
6 or 8 baths have been taken and the use of car- 
bonated baths begun, provided such reduction is 
considered necessary. Usually, the patient's 
sensation is a safe guide to the regulation of 
temperature. The bath should feel pleasant and 
quite definitely warm throughout the period of 
immersion, and the patient should be cautioned 
and told to report at once any tendency to chill. 
The movements are very simple Swedish move- 
ments, and, as recommended by Schott, comprise 
19 exercises, so planned as to bring into action 
every muscle group in the body. The move- 
ments are intended to produce without fatigue 
the beneficial result of exercises, and are of de- 
cided value in the treatment of almost all cases to 
which the baths are applicable. 
Effect of Baths.-(1) There is a fleeting sense 
of oppression and dyspnea; (2) a feeling of exhil- 
aration and well-being; (3) slowing of the pulse, 
and, coincidently, a fuller and stronger beat; (4) 
brightening of skin, nails, and mucous membrane, 
indicating relief of cyanosis, freer capillary circu- 
lation; (5) secondary reduction of pulse tension 
with maintenance of lower rate; (6) marked 
reduction in cardiac area, most marked primarily 
in the right heart, but involving both lateral and 
vertical dimensions. See Heart-disease 
(Organic). 
SCIATICA.-Pain in the course of the sciatic 
nerve. This may be confined to the proximal 
half of the thigh, or may follow the entire course 
of the nerve and its branches. The pain is con- 
stant and gnawing, subject to exacerbations, 
and occurs most commonly in adults of middle 
age. Double sciatica is rare. 
Causes.-As a rule, neuritis of the sciatic nerve 
or of its cords of origin exists. Rheumatism or 
gout, exposure to cold, heavy muscular exertion, or 
a thorough wetting, cause primary sciaticas, while 
compression by ovarian or uterine tumors, by 
lymphadenoma, the fetal head, or occasional 
lesions of the hip-joint induce secondary sciaticas. 
The duration and course are variable, but 
chronic sciatica usually lasts for months, or, with 
remissions, for years. 
Diagnosis requires a distinction between primary 
sciatica and the secondary affection due to diseases 
of the pelvis or spinal cofd. Pelvic tumor and 
lumbago should be excluded. Hip-joint affec- 
tions cause no tenderness along the course of the 
nerve, and sacroiliac disease has usually radiating 
pain. When the nerve-trunks of the cauda 
equina are pressed upon, there are bilateral pain 
and disturbances of sensation. The severe light- 
ning pains of tabes are easily distinguished. SCILLA 
SCLERODERMA 
Treatment requires that careful and systematic 
pelvic examination be made, and that constitu- 
tional conditions should receive appropriate atten- 
tion. Salicylates are useful in rheumatic cases, 
when the onset has been acute and accompanied 
by fever. Potassium iodid will remove a suspicion 
of syphilis, and salines improve gouty cases. 
Rest in bed with fixation of the limb on a long 
splint will relieve obstinate and protracted cases. 
Warm or mud-baths are sometimes satisfactory. 
Quinin, antifebrin, and antipyrin are of doubtful 
use. Local applications of a hot iron, thermo- 
cautery, or blisters may temporarily relieve pain. 
Cocain, in doses of 1/8 to 1/4 of a grain, may be 
used by deep injection into the nerve. An acu- 
puncture needle may be thrust into the painful 
spot for a distance of 2 inches, and left there for 
from 15 to 20 minutes. Injections of distilled 
water or normal saline solution into the nerve 
may relieve the pain. Electricity is uncertain, 
and morphin should be withheld as long as possible 
or until the pain is unbearable. 
Nerve stretching, in very obstinate cases, is some- 
times successful, but often the condition recurs. 
The incision is begun at the gluteal fold and carried 
down the back of the thigh for 4 inches. The 
nerve is exposed, properly cleaned from the 
surrounding tissues, and then raised with a blunt 
hook on the forefinger. It should be stretched 
both centrifugally and centripetally, maintaining 
the traction for about 5 minutes. The surgeon 
must decide the amount of force to use in each 
case by the size of the nerve. Experiments show 
that the breaking strain of a healthy sciatic nerve 
is never under 80 pounds. 
SCILLA.-See Squill. 
SCLEREMA NEONATORUM.-Sclerema is a rare 
disease, which occurs in the early days of life, and 
affects those, chiefly, who are weak and feeble, 
born in cold weather and in poor hygienic sur- 
roundings. It is characterized by hardening of 
the skin and subcutaneous tissues. 
The causes of sclerema are generally not local, 
the most important etiologic factors being great 
feebleness, with lowering of the body temperature, 
and, in consequence, hardening of the subcutaneous 
fat. 
Symptoms.-Soon after birth spots of circum- 
scribed hardness appear on the skin. These are 
often first seen on the feet or calves of the legs, but 
soon spread over the greater part of the body. 
The skin has a waxy and glistening appearance, 
and is hard and cold; the limbs becoming thick, 
stiff, and misshapen. The temperature is sub- 
normal-reaching in some cases 83° to 86° F. in 
the rectum. The infant soon grows weak, som- 
nolent, and refuses to take its food. The breath- 
ing becomes rapid and superficial, and no pulse 
can be felt. 
The duration of the disease is 3 or 4 days, and 
death occurs slowly and quietly. If recovery 
takes place, there is gradual improvement in the 
circulation and nutrition, and later a disappear- 
ance of the areas of induration. 
The treatment should consist of artificial heat- 
the child should be placed in an incubator. In- 
unctions of hot oil with massage should be given, 
and the nutrition kept up by stimulants and care- 
ful feeding. 
SCLERITIS (Episcleritis).-Inflammation of the 
scleral tissue characterized by a purplish injection 
of the ciliary, deep pericorneal, and conjunctival 
vessels. 
Symptoms and Diagnosis.-If the conjunctival 
vessels are kept empty by gentle pressure, the 
bluish scleral vessels are seen more clearly. There 
is considerable pain on pressure and some local 
swelling. Carefully examined, a flat nodule made 
up of minute vesicles is seen lying about 3 mm. 
from the edge of the cornea (episcleritis). The 
disease is intimately connected with rheumatic 
disorders, syphilis and tuberculosis. The diag- 
nosis is easily made, and depends upon the char- 
acteristic local condition and rheumatic, gouty, 
syphilitic or tuberculous history. Most cases are 
rheumatic in origin. The course of the disease is 
protracted, sometimes one nodule after another 
being formed until a large portion of the sclera is 
occupied by blotches. Relapses are frequent, and 
are closely connected with general rheumatic 
paroxysms. The pain is more or less severe, and for 
the time the eye is practically useless for near work. 
Treatment is general. Salicylates and the ordi- 
nary rheumatic treatment should be instituted; or 
if syphilis or tuberculosis is defined, the respective 
treatment should be inaugurated. Ordinarily, 
local treatment should be avoided, but in chronic 
cases massage with yellow ointment may be tried. 
For the relief of the pain, moist heat and pressure 
are advised. If the choroid is involved, atropin is 
indicated. See Tuberculosis (Ocular). 
SCLERODERMA (Hide-bound Disease).-A 
disease characterized by circumscribed or diffuse in- 
duration, rigidity and stiffening of the integument, 
terminating in atrophy. 
Symptoms.-The disease is exceedingly rare. 
The skin manifestations may be preceded or 
accompanied by disturbance of cutaneous sen- 
sibility, such as pain, prickling, tingling, formi- 
cation, etc., and by muscular cramps. The disease 
begins as a pronounced stiffening or hardening 
of the skin, which progresses gradually, or more 
rarely rapidly, until marked induration results. In 
some cases an edematous stage may precede the in- 
duration. When the disease is typically developed, 
the skin is thickened, tense, hard, and immovable, 
acquiring in an advanced stage the feel of frozen 
skin, leather, or even wood. It is bound down to 
the structures beneath, and is incapable of being 
lifted. There is usually pigmentation of a yellow- 
ish or brownish hue. 
After a variable duration the stage of induration 
passes on to the stage of atrophy. The skin then 
becomes thinned, shiny, and tensely stretched 
over the bony prominences. The phalangeal 
joints are apt to become ankylosed in a semiflexed 
position (sclerodactylia). 
The course of the disease is chronic, although in 
rare cases it may be acute. The general health is, 
as a rule, not compromised. The parts most 
affected are the neck, face, forearms, chest, and 
lower extremities. SCLEROSIS, CEREBROSPINAL 
SCROFULA 
Etiology.-Scleroderma occurs chiefly in early 
adult and middle age, and is far more common in 
women than in men. Exposure to cold and wet, 
rheumatism, and nerve shocks have been causal 
in many cases. The disease is brought about 
through the implication of the nervous system. 
Pathology.-The chief changes noted in sclero- 
derma are an increase and condensation of the 
connective tissue in the corium and subcutaneous 
tissue, an increase in the elastic tissue, and a 
diminution in the caliber of the blood-vessels. 
Later there is atrophy of the subcutaneous 
tissues. 
Diagnosis.-The peculiar immobile, indurated, 
tightly adherent condition of the skin is highly 
characteristic of the disease. Morphea is looked 
upon by most writers as a circumscribed form of 
scleroderma. 
Prognosis should be guarded; in some cases the 
disease undergoes spontaneous involution; in many 
it persists throughout life. 
Treatment.-Internal treatment is to be based 
upon general principles, arsenic, quinin, and cod- 
liver oil being frequently of value. Locally, baths, 
massage with oily substances, and electricity may 
be employed with benefit. 
SCLEROSIS, CEREBROSPINAL.-See Dissemi- 
nated Sclerosis. 
SCLEROSIS, SPINAL.-See Amyotrophic 
Lateral Sclerosis, Lateral Sclerosis, Para- 
plegia. 
SCLEROTOMY.-See Glaucoma. 
SCOLIOSIS.-See Spine (Curvature). 
SCOPARIUS (Broom).-The dried tops of the 
common broom plant, Cytisus scoparius. Its prop- 
erties are due to a neutral principle, scoparin, and 
an alkaloid, spartein. It is diuretic and laxa- 
tive; in large doses it is cathartic and emetic. 
It is a favorite remedy in cardiac dropsy and 
kidney complaints. Dose, 5 to 30 grains. There 
are no official preparations. See Spartein. 
SCOPOLA.-See Hyoscyamus. 
SCOPOLAMIN.-See Hyoscyamus. 
SCOPOLAMIN-MORPHIN ANESTHESIA.-See 
Anesthetics (Anesthetic Mixtures). 
SCORBUTUS.-See Scurvy. 
SCORPION BITES.-See Bites and Stings. 
SCOTOMA.-See Field of Vision. 
SCREAMING, NIGHT.-See Nightmare. 
SCROFULA (Tuberculous Adenitis; Lymphaden- 
itis; King's Evil).-A morbid condition, usually 
constitutional, and frequently hereditary, charac- 
terized by glandular tumors having a tendency to 
suppuration, and leaving indolent ulcers very 
stubborn to treatment. It is now generally 
accepted as a manifestation of tuberculosis. 
The term is gradually falling into disuse. 
Etiology.-It is most generally seen in children 
and young adults, especially those who suffer from 
nasopharyngeal catarrh. It is very common in 
the negro race. The bacillus of tuberculosis is the 
specific cause of the disease. 
Pathology.-The cervical glands are those most 
frequently enlarged. The tubercles form first in 
the lymphoid follicles, finally breaking through 
the capsule. Generally, caseation ensues with 
subsequent liquefaction, and suppuration begins, 
with the establishment of a sinus. 
Symptoms.-There is usually a history of tuber- 
culosis in the father or mother, or a neglected 
nasopharyngeal catarrh. One gland may be first 
affected, becoming enlarged and painful. Usually 
the gland is hard, the color of the skin overlying 
being unaltered. Soon the lymph-channels con- 
vey the virus to neighboring glands, which be- 
come diseased, break down, and suppurate. 
Often the process of liquefaction does not come 
on until late, and the gland may seem to remain 
of one size indefinitely. The temperature is 
variable-from normal to 102° F.; the child seems 
peevish, and endeavors to protect the affected side 
by inclining the head in the opposite direction. 
The body is often greatly emaciated, and signs of 
grave anemia are very prominent. 
Diagnosis.- 
Scrofula. 
Hodgkin's 
Disease. 
Lymphatic 
Leukemia. 
Lymphoma. 
1. Most com- 
mon in chil- 
dren and 
young adults; 
cervical 
glands most 
frequently 
enlarged. 
1. Not com- 
mon in chil- 
dren; princi- 
pally cervi- 
cal or sub- 
m a x i 11 ary 
glands. 
1. Middle life. 
1. Early life; all 
glands in- 
volved. 
2. Glands oft- 
2. Glands not 
2. Glands not 
2. Glands freely 
en painful. 
tender. 
tender. 
movable, not 
especially ten- 
der. 
3. Glands sup- 
3. Glands 
3. Glands rare- 
3. Glands rarely 
purate. 
rarely sup- 
purate. 
ly suppurate. 
suppurate. 
4. Blood may 
4. Blood 
4. Marked per- 
4. Blood shows 
show evi- 
shows signs 
s i s t e n t in- 
signs of sim- 
dence of ane- 
mia. 
of moderate 
anemia. 
crease of 
white blood- 
corpuscles. 
See Leuke- 
mia. 
pie anemia. 
Prognosis.-If the disease is located in the 
cervical region or near the external surface in 
any portion of the body, prognosis is favorable. 
Treatment.-The best of hygienic surroundings, 
with good and nutritious food, are demanded. 
Tonics are valuable, such as the iron iodid (5 to 15 
minims) 3 times a day. The elixir of the phos- 
phates of iron, quinin, and strychnin (5 to 30 
minims), according to age. 
An emulsion of cod-liver oil is also very valuable: 
I). Syrup of the iodid of iron, 5 vj 
Cod-liver oil, 3 iv 
Whisky, 5 j 
Bitter-almond water, 5 ij 
Cinnamon water, 3 ij 
Yolks of two eggs, 
Water, enough to make 3 x. 
Beat up the eggs in a mortar for 15 minutes, 
and gradually add the oil; then the other 
ingredients, the whisky being added last. 
Two teaspoonfuls 3 times a day. 
If suppuration ensues, the glands must be 
excised. SCROTUM, DISEASES 
SCROTUM, DISEASES 
Tabes Mesenterica.-This is an involvement of 
the retroperitoneal lymph-glands, and is common in 
young children. The limbs and trunk are greatly 
wasted, and the belly becomes very prominent 
from tympanites. There is often diarrhea, with 
offensive stools, yet the bowels are not generally 
the seat of tuberculosis. There may be infection 
of the peritoneum, also giving rise to an uneven, 
nodular, tender, and painful enlargement, easily 
detected on palpation. 
SCROTUM, DISEASES.-Edema may occur in 
nephritic subjects, causing great swelling; and a 
similar affection, generally inflammatory, is occa- 
sionally seen in infants. 
Inflammation is quite common, but unless asso- 
ciated with extravasation of urine, or unless the 
nutrition is much enfeebled, as in specific fevers, 
sloughing and gangrene rarely occur. Inflamma- 
tion of the scrotum may arise from injury, eczema, 
irritation of urine, retained perspiration, or may 
spread from neighboring tissues. The swelling is 
much greater proportionately than the pain, heat, 
and redness. See Testicle (Inflammation). 
Elephantiasis.-Enormous hypertrophy of the 
tissues of the scrotum may be caused by lymphatic 
obstruction or by repeated attacks of inflamma- 
tion, as in cases of urinary fistula. The skin and 
subcutaneous tissues only are affected, the cellular 
elements and the fibrous tissue being immensely 
increased, while all the interstices are filled with 
lymph, or, in rarer cases, with a mixture of 
lymph and chyle. Hydrocele is usually associated 
with elephantiasis, and the skin of the penis 
may become involved, but the testes are never 
affected. 
Epithelioma is of interest from the fact that its 
origin can nearly always be traced to local irrita- 
tion; it formerly was often called chimney-sweeps' 
cancer, from the frequency with which it occurred 
in chimney-sweepers as the result of irritation of 
soot. It begins as a wart or nodule, which slowly 
spreads at the margin as it decays and ulcerates 
in the center. Induration is its chief feature. 
The edges are raised, hard, and ill defined; the 
base is covered with decaying epidermis and florid 
granulations which discharge a thin, offensive fluid, 
and the tissues around are swollen and edematous. 
At first it can be pinched up from the structures 
beneath, and merely feels like an induration in 
the skin; soon it infects the lymphatic glands in 
the groin, spreads to the rest of the scrotum and 
the penis, and involves the testicles as well. 
Fortunately, its character is so well known among 
those Hable to it (soot may cause it in other parts 
of the body, and there is reason to believe that tar 
may do the same), and its progress (for epitheli- 
oma) is so slow, that removal in time is usually 
possible. Even if the inguinal glands are enlarged 
and broken down, the whole of the disease may 
sometimes be successfully eradicated. 
Examination of Scrotal Swellings.-Swellings 
of the scrotum are divided into those that occupy 
the canal as well as the scrotum, and those that 
are confined to the latter situation. The distinc- 
tion is made by feeling the cord immediately below 
the pubes: whether it is the natural size, with all its 
components distinct, or whether it is thickened or 
concealed in any way. 
Swellings that Occupy the Canal as well as the 
Scrotum.-Those that are reducible are: 
Bubonocele and scrotal hernia, which may be 
recognized by the way in which they disappear 
whether they consist of intestine or omentum. 
V aricocele, diagnosed by its characteristic feel, 
the way in which it disappears when the patient 
lies down and the scrotum is raised, and refills in 
spite of the pressure of the finger on the ring. 
Congenital hydrocele, known by its translucency. 
As the neck of the canal is often long and narrow, 
reduction is not always easy. 
Those that are irreducible are: 
Hernia, which cannot be returned because it is 
strangulated (in which case there is no impulse on 
coughing), or because it is irreducible-i. e., so 
altered in shape or so tied down by adhesions 
that it cannot pass back. In strangulation con- 
stitutional symptoms are also present. 
Infantile Hydrocele.-The neck of the tunica 
vaginalis is obliterated only at the internal 
abdominal ring, and a collection of fluid extends 
from the bottom of the scrotum along the inguinal 
canal. The slow formation, commencing below 
and extending upward, the translucency, and the 
absence of true impulse (if it extends really into 
the canal, there may be a kind of shock trans- 
mitted) are distinctive. 
Inflammatory Affections of the Cord.-In urethral 
epididymitis this is sometimes swollen to a con- 
siderable size; in tubercular disease the vas only 
is thickened, and all the structures of the cord 
can be isolated. 
Growths on the Cord.-The most common is 
encysted hydrocele, a small, round, and tense fluid 
swelling, due to incomplete obliteration of the 
funicular portion of the tunica vaginalis. It is 
movable in the canal, but cannot really be reduced, 
and it is adherent to the cord, forming part of it 
and moving with it. 
Lipoma, sarcoma, and other growths may occur, 
but they are very rare. Secondary infiltration is 
always present in malignant disease of the testis, 
if the gland is not speedily removed. Hematocele 
of the cord has been described. See Hematocele. 
Swellings Confined to the Scrotum.-Of those 
connected with the scrotum itself are: 
Edema.-In Bright's disease the whole scrotum 
sometimes becomes enormously distended without 
the legs being much affected. 
Elephantiasis.-In the tropical variety there can 
be no hesitation, but occasionally a greatly thick- 
ened and hardened condition, not so plainly 
recognized, occurs as a result of neglected stricture. 
Lipoma, epithelioma, and other varieties of new 
growths may occur. 
Those connected with the testis and its coverings 
may be solid or fluid. The former include in- 
flammatory diseases and tumors of the testis. 
The chief difficulty occurs with hematocele and old 
hydrocele, the walls of which may be so thick that 
they are practically solid. The latter may be 
connected with the tunica vaginalis (hydrocele or 
hematocele), the testis or epididymis (encysted SCURVY 
SCURVY, INFANTILE 
hydrocele), or the lower end of the cord (hydro- 
cele of the cord); or they may be independent 
cysts-dermoid, for example, or hydatid. Some 
difficulty may arise from what is known as hydro- 
sarcocele, a collection of fluid in the tunica vaginalis 
surrounding and concealing an enlargement of the 
testis, and the diagnosis may remain uncertain 
until the fluid is drawn off (Moullin). See 
Testicle (Diseases). 
SCURVY. (Scorbutus).-A constitutional dis- 
ease, characterized by a spongy condition of the 
gums and by a tendency to hemorrhages into the 
gums, muscles, joints, and internal organs. The 
blood shows the same characteristics as seen in 
the secondary anemias. 
Etiology.-It is principally due to eating too 
much salt meats or corned meats, and not enough 
of fruits and vegetables. It is most often ob- 
served in sailors, soldiers, miners, and in remote 
habitations, where there is a limited amount of 
proper food. 
Pathology.-The gums are soft and spongy, often 
being ulcerated to such a degree that the teeth 
drop out. There may be hemorrhages into the 
mucous surfaces, as into the gums. Often ecchy- 
motic spots are seen on the external surfaces, and 
occasionally in the serous membranes. 
Symptoms are usually of slow development and 
in early stages they are manifested by fatigue, by 
a craving for acid foods, and by constipation. 
There is an anemic appearance of the skin, or it 
may have a yellowish appearance. The gums are 
congested, and bleed on the slightest touch, and 
hemorrhagic spots are found dotted over the 
mucous membrane of the mouth, principally of 
the gums. 
Prognosis is good. 
Treatment.-Prophylactic treatment consists in 
a diet including onions, limes, lemons, oranges, 
canned vegetables, etc. Fractional doses of 
calomel (1/4 of a grain) should be given every 
hour until 6 doses have been taken, followed by a 
saline purge, if necessary. Subsequently, the diet 
should be principally composed o*f fruits and 
vegetables. 
When convalescence is established, a tonic con- 
taining iron may be given: 
I|. Arsenous acid, gr. j 
Strychnin, gr. ss 
Mass of carbonate of iron, 3 iij • 
Divide into 30 pills. One pill after meals. 
Or- 
I|. Tincture of ferric chlorid, 3 iv 
Aromatic elixir, 3 iv 
Water, enough to make 5 iij- 
One teaspoonful after meals. 
SCURVY, INFANTILE.-Infantile scorbutus is a 
constitutional disease associated with imperfect 
nutrition due to some prolonged error in diet. 
It is manifested by rapid and progressive cachexia, 
profound anemia, etc. 
Etiology.-The cause of scorbutus is probably of 
chemic origin, due to the continued use of food that 
either lacks some elements required for the child's 
nutrition or which furnishes them in such a form 
that the child cannot assimilate them. 
Scurvy occurs nearly always between the sixth 
and twenty-fourth months, and in nearly all cases 
in babies who are artifically fed. It occurs in the 
well-to-do as well as in the poor and neglected- 
more frequently in the former, as in the latter class 
the diet is, as a rule, more varied, and although not 
in every respect suited to proper nutrition, it 
contains the antiscorbutic elements. A large 
majority of the cases reported have occurred in 
babies exclusively fed on condensed milk, sterilized 
milk, or on the various proprietary foods com- 
bined with sterilized milk, or on these foods pre- 
pared without the addition of the proper pro- 
portions of milk and cream. 
Pathology.-Hemorrhages occur frequently in 
the skin, mucous membranes, muscles, viscera, 
and subperiosteal tissues of the bones. Extensive 
ulceration of the gums, with exuberant granula- 
tions often overlapping the teeth, are common in 
advanced cases. The blood presents all the char- 
acteristics of anemia, such as a diminution of the 
red blood-corpuscles and a decrease in the per- 
centage of hemoglobin. 
Symptoms.-The onset is gradual; the child be- 
comes anemic, and suffers with more or less severe 
attacks of gastrointestinal disturbances. The 
appetite is diminished or irregular; the stools may 
be normal, but are often irregular, pasty, and gray 
in color; sweating of the head, as in rickets, has 
been noticed, and the child is often feverish. 
These are simply symptoms of indigestion, which 
generally, but not always, precede for a variable 
length of time the symptoms of scurvy. 
The first symptom which suggests the true na- 
ture of the disease is a sensitive condition of the 
bones, the infant crying when the affected parts 
are touched. It will also be noticed that the gums 
are congested and bleed readily. As the disease 
progresses, the limbs become swollen. Only the 
legs are usually affected, but the forearm may 
also become swollen and tender. The enlargement 
of the limbs may continue until they become 
double their natural size. The swelling is not 
usually accompanied by any local heat or dis- 
coloration, but the skin has a white, transparent 
appearance. When the child is not disturbed, it 
will often lie for hours in one position, the legs being 
kept extended or slightly flexed, but absolutely 
motionless; but when it is disturbed or handled, 
there is apparently intense pain, which is indicated 
by piercing screams. 
Ecchymoses may occur upon the skin over the 
swelling or upon other parts of the body, especially 
about the eyes. Intraorbital hemorrhage may 
give rise to exophthalmos. The gums are not 
affected when the teeth have not appeared; but 
when any of the teeth have been erupted, the gums 
about them become swollen, spongy, and bleeding, 
and may ulcerate; the teeth may become loosened 
and fall out, and the mouth may be filled with a 
bloody and foul-smelling secretion. 
Diagnosis.-In certain cases rickets may re- 
semble scurvy, but in rickets there occur curvatures 
of the bones and enlargement of the epiphyses, SCUTELLARIA 
SEA-BATHING 
while the swelling of the shaft of the bones, the 
gingivitis, and the purpura are absent. The im- 
mobility of the limbs has led to a diagnosis of 
paralysis; the swelling and the pain to diagnosis 
of rheumatism, hip-joint disease, fracture, osteo- 
sarcoma, etc.; but errors in diagnosis may be 
avoided by attention to the associated symptoms 
of swelling and tenderness of the extremities, to 
the fungous and bleeding condition of the gums, 
and to the cachexia and anemia. Whenever any 
doubt exists as to the nature of the affection, the 
results of treatment will speedily establish the 
diagnosis. 
Prognosis.-The course is slow and progressive, 
and when left untreated, the child may finally die 
of exhaustion. On the other hand, cases which 
receive proper treatment early never develop the 
graver forms of the disease, and in them the prog- 
nosis is invariably favorable. 
Treatment.-The treatment of infantile scor- 
butus consists of substituting for the improper diet 
one of fresh milk modified according to the child's 
age. See Infant Feeding, Milk (Modified). 
The juice of one orange, or even more, should be 
given in the 24 hours. Children usually take this 
readily; but should they refuse to do so, they 
should be forced to take it. Beef-juice, a tea- 
spoonful added to the milk, or given alone, should 
be given 3 times a day, and 1 to 3 grains of the 
ammoniated citrate of iron in the orange-juice 3 
times a day. The child should receive a warm 
salt bath daily, and should be in the fresh air and 
sunlight as much as possible. 
SCUTELLARIA.-Skullcap. The dried plant 
S. lateriflora; with reputed properties as a tonic 
nervine in tremors, chorea, hysteria, etc. Dose, 
of the fluidextract, 10 to 30 minims. 
SEA-BATHING.-Sea-bathing may be regarded 
as a powerfully stimulating cold-water bath, from 
which it differs only in the action of its ingredients. 
A question often asked is: Does sea-bathing differ 
from a salt-water bath taken elsewhere? It 
differs in the admixture of organic and inorganic 
mechanic particles in the water; in its varying de- 
gree of wave-motion; and in producing an effect, 
otherwise uriattainable, by the alternation in ex- 
posure of the body to water and to air. Sea-water 
is more equable in temperature than the surround- 
ing air, and is, as a rule, warmer in winter and 
cooler in summer than other.water. Its tempera- 
ture varies during the day and from day to day, 
but in a less degree than air. Sea-water holds in 
solution an amount of salts varying according to 
locality. Mediterranean water is richest in salt. 
The waters of the Baltic Sea are less salty, con- 
taining about 0.5 percent. Five-sixths of the 
salts in sea-water consist of sodium and magne- 
sium chlorids. The sulphates and carbonates of 
calcium, magnesium, and potassium constitute 
the principal other salts. Artificial salt baths can- 
not give the motion of sea-water, which varies 
constantly and according to the size and force of 
the waves; and the effect of sea-bathing is to a 
great degree dependent upon this point. Waves 
in any degree powerful expose the upper part of 
the body to their coming, and the lower part to 
their receding; and cutaneous nerves are not only 
influenced by the temperature, but also by the 
force of the water and of other substances, such as 
sand, mixed with it. The alternate exposure to 
air and water occasioned by waves is peculiar to 
sea-bathing, and produces its impression on the 
cutaneous nerves. 
The time of day for sea-bathing depends on the 
weather, the season, the individual, and the tide. 
As a rule, it is inadvisable to bathe when the stom- 
ach is empty, and never after a full meal. Delicate 
persons particularly should be warned on these 
points. The duration of a bath is to be measured 
by the constitution of the bather, the force of the 
waves, and the temperature of the water. Five 
minutes are sufficient for weakly persons, while 
immersion for 1 or 2 minutes may suffice. A good 
rule is to leave the water as soon as reaction mani- 
fests itself. 
The warm sea-bath is to be recommended with 
advantage when the cold sea-bath is unattainable. 
Such baths are analogous to warm, common-salt 
baths. The tepid swimming bath of sea-water is 
sometimes appropriate, can be used in winter, and 
offers the advantage of combination with muscular 
exercise. The physiologic effect of sea-baths is 
similar to that of sea-air. The usual effects are 
increased appetite and increased weight of body. 
When loss of appetite, headache, digestive dis- 
turbances, and loss of weight ensue from sea- 
bathing, the shock of the bathing is too great, or 
the baths are too long continued or too frequently 
taken, or possibly the increased demand upon the 
system is too great. 
There are cases unsuited for sea-bathing. 
Persons affected with certain diseases of the heart 
(see Schott Treatment, Heart-disease (Or- 
ganic)), diseases of the blood-vessels and lungs, 
angina pectoris, epilepsy, organic diseases of the 
nervous system, enlargement of the liver, or other 
organic disease of the abdominal viscera should 
avoid bathing in the open sea. Violent palpitation 
and dyspnea extending over many months may 
ensue, as well as general sleeplessness, loss of 
appetite, and emaciation. Except on warm days 
and in quiet water, old persons, especially those 
with feeble circulation, should avoid bathing in 
the open sea. Recent rheumatic joint affections 
are injured by sea-bathing, and it is hazardous in 
cases of chronic pneumonia, with pleuritic effusion, 
and in tuberculosis of the lungs. 
Cases benefited by sea-bathing are those with 
weakness or atony of the skin-e. g., with a tend- 
ency to profuse perspiration, and who take cold 
easily on exposure to winds or drafts. In scrofu- 
lous complaints there is often more advantage in 
sea-bathing than in climatic treatment. In 
muscular rheumatism sea air, combined with the 
moderate use of sea-bathing, is most useful. So- 
called nervous rheumatism is often benefited by 
the use of gentle sea-bathing. Functional diseases 
of the nervous system are much benefited by sea- 
baths adapted to the individual case. Persons 
with a tendency to neuralgia, to nervous asthma, 
or to certain forms of hysteria are often unable to 
stand sea air for a long period of time. SEA-BATHING 
SEA-SICKNESS 
According to Kruse, the prevalent objections to 
sea-bathing in anemia are not justified. The un- 
toward results are attributable to the injudicious 
employment of the baths. Lack of care in cold 
bathing is accountable for acute cardiac dilatation, 
additional weakening of the heart-muscle, which 
in anemia is less vigorous than normally, and which 
explains the faintings, weaknesses, etc., after pro- 
longed baths. 
Cold sea-baths are contraindicated in anemia 
complicated with diseases of important organs, 
such as ulcer of the stomach, chronic inflammatory 
processes in the uterus and its appendages, etc., 
or in anemia which has led to great debility and 
anorexia. The latter is soon relieved by sea air. 
The following rules are recommended: 
1. Anemic patients should not bathe for two days 
after arrival at the seashore. 
2. They should never bathe when fasting. 
3. They should not take baths every day. 
4. The first baths must not last over 1 minute; 
later on they may be extended to 3 or 4 minutes, 
but never longer. 
5. The bather should undress rapidly and dip 
into the waves immediately, without waiting for 
the body to cool. 
6. The patient should not move about, but 
remain as passive as possible while in the water. 
7. No baths are to be taken in stormy weather, 
to avoid overexertion. 
8. After each bath the skin must be carefully 
dried and rubbed. 
9. The patient should not exercise, but should 
rest in bed for an hour after each bath. 
10. As a rule, anemic patients should not bathe 
oftener than every second day. 
11. No object is attained by beginning the sea- 
bath treatment with warm baths. They may do 
harm. An exception to this rule is in parametric 
exudations; in these warm sea-baths may be used, 
withjwarm wet packs on the abdomen during the 
night, associated with abdominal massage. These, 
together with prolonged stay in the sea air, prove 
efficacious. 
12. The patient should not exercise much at the 
seashore; even sitting there for an occasional hour 
proves sufficiently tiring. 
13. Patients with profound anemia should limit 
walking to the absolutely necessary; they should 
sit or lie, well wrapped, in the open air for the 
greater part of the day. 
14. The insomnia that often sets in while at the 
seashore is most frequently due to overexertion. 
15. Preparations of iron assist, especially in the 
beginning, and are in most instances well borne at 
the seashore. The most desirable form is sac- 
charated ferric carbonate; but the use of ferrugin- 
ous waters at the seashore is not appropriate in 
anemias. 
16. The patient should not yield to the extreme 
appetite which often sets in at the seashore, lest 
the stomach soon become unable to perform its 
functions. 
17. Alcoholic stimulants should be used most 
sparingly; patients should be warned against brandy 
and heavy wines. Alcohol promotes fatty degen- 
eration of the muscles, and particularly of the 
heart. 
Three hundred cases treated by Kruse with the 
above precautions proved the efficacy of sea-baths 
in anemia. 
Many states of weakness manifesting themselves 
in various ways unsuitable for classification, such 
as inability to sustain mental or bodily efforts, 
tendency to abortion, leukorrhea, etc., are greatly 
benefited by judicious and well-timed sea-bathing. 
The fear of sea-bathing during menstruation is a 
teaching handed down to us from by-gone 
generations. However, any healthy woman may 
bathe in moderately warm water during menstru- 
ration, if she takes proper precautions against sub- 
sequent cold. Mirouiff states that alkaline baths 
at 27° or 28° C. during menstruation by patients 
suffering from gynecologic troubles act as excel- 
lent sedatives. Moreover, the quantity of blood 
lost is not increased or affected, save possibly to 
be slightly diminished. In addition, pain is 
soothed and any accompanying inflammation of 
the genitals mitigated. Salt baths are, therefore, 
of real benefit during the flow. Sea-baths, far from 
deranging, favor menstruation. Unless there is 
grave uterine disease, sea-baths prolong the period 
of sexual activity and increase fruitfulness. 
SEA-SICKNESS.-The nausea and vomiting 
affecting certain persons at sea, or those who are 
subjected to any undulating motion, like that of a 
vessel. 
Etiology.-The exact cause of the condition has 
never been definitely settled. Very likely no one 
cause is active in every case. Cases seem divisible 
into those primarily of nervous origin and those of 
gastric origin. Imagination alone may cause mal 
de mer. Disturbance of equilibrium and exag- 
gerated conceptions of the relationship of space, 
may result in nausea and vomiting. Eye-strain 
may be provocative of an attack. Some be- 
lieve that sea-sickness is due to hyperemia of the 
semicircular canals; others that it results from 
disturbance of the endolymph. Congestion of the 
cord and medulla is also regarded in the etiology. 
The same phenomena may be caused by swinging 
or by traveling, and even by landing after voyaging. 
An important point to bear in mind is that the 
mere fact of a patient's being on a vessel does not 
preclude the possibility of volvulus, appendicitis, 
intestinal obstruction, or other complication re- 
quiring prompt and urgent attention. 
Treatment.-In genuine sea-sickness the bromids 
furnish a means of prophylaxis. From 5 to 10 
grains should be given 3 times daily for several 
days before sailing. After sea-sickness has be- 
gun, they are best given in an effervescing mix- 
ture-e. g.: 
I). Citric acid, 3 ij 
Distilled water, 3 iv. 
Mix and add: 
I). Potassium or sodium bromid, 3 j 
Potassium bicarbonate, 3 j 
Distilled water, 3 iv. 
Take a tablespoonful of each and drink while 
effervescing. SEA-SICKNESS 
Bromural is highly recommended as a prophy- 
lactic. 
For an hour before embarking strychnin sul- 
phate, arsenate, or hypophosphite, 1/120 grain, 
may be taken every quarter of an hour; or the 
combination of 1/120 grain of each of above 
compounds of strychnin may be taken for 3 days, 
3 times daily, with 1/2 grain of podophyllum each 
night. 
For 3 days before sailing, and for 3 days there- 
after take: 
SEBORRHEA 
and ginger ale, are less likely to be rejected by 
the stomach than are the usually administered 
beef-tea and chicken broth. Do not insist too 
much on the value of fresh air on the deck. A 
day or two in bed with restricted diet is sometimes 
of more benefit than fresh air secured at the 
expense of one's reserve fund of energy. When 
there is an opportunity to advise prospective 
voyagers, always insist on careful diet for several 
days before going to sea; and upon a liberal 
calomel and saline purge about 48 hours before 
sailing. See Calage. 
SEA-WATER INJECTIONS.-Sea-water especi- 
ally collected and prepared carefully with aseptic 
precautions is injected preferably behind the great 
trochanter in adults, in infants over the scapula. 
Marked and rapid tonic effects are reported by 
the French advocates of this treatment as re- 
gards the bodily functions and general condition. 
This treatment is said to be valuable in gastro- 
intestinal disorders, especially in infants, in skin 
diseases, in varicose ulcers, anemia, chlorosis and 
tuberculosis, etc. The initial doses are genetally 
20 to 50 c.c., depending on the disorder. The 
results obtained are discredited by American 
observers who have found this treatment of no 
greater value than simple injections of normal 
saline solution. 
SEBACEOUS CYSTS.-These are most common 
during middle life, and occur on any portion of 
the body, though most generally upon the scalp, 
back, shoulders, and face. They are mostly mov- 
able, superficially situated, and adherent to the 
skin. The contents are usually of yellowish, 
curdy material. They probably are formed by 
dilatation of a hair follicle, with sebaceous secre- 
tion. If untreated, they frequently become in- 
flamed, suppurate, and occasionally calcify. 
Papillomata, horns, and epitheliomata may arise 
from their internal surfaces. Sebaceous cysts are 
to be differentiated from dermoid cysts, which lie 
under the deep fascia, the skin being freely mov- 
able over them; a sebaceous cyst lies in the corium, 
and moves with it or is adherent to it. 
Treatment.-Sebaceous cysts should be removed 
before they become inflamed, by a linear incision 
through the skin down to, but not into, the tumor, 
separating the cyst with the scalpel-handle from 
the connective tissue surrounding, and removing 
without evacuating the contents. In any case, 
the cyst-wall must be removed. Fatty tumors are 
sometimes mistaken for sebaceous cysts or wens, 
but the treatment is the same in either case, and a 
distinction is immaterial. 
SEBORRHEA (Dandruff; Pityriasis).-A dis- 
order of the fat-producing glands characterized by 
an increased and altered secretion of sebum, pro- 
ducing an oily or scaly condition upon the skin. 
Symptoms.-There are two forms-seborrhoea 
oleosa and seborrhcea sicca. 
Seborrhoea Oleosa.-This form manifests itself 
as an inordinate oiliness of the skin. The parts 
usually affected are the forehead, cheeks, and nose. 
The mouths of the follicles are 'dilated, and there 
is often an enlargment of the superficial blood- 
vessels. The face is dirty and begrimed, owing 
1J. Extract of taraxa- 
cum, 
Compound extract 
of colocynth, 
each, gr. xx 
Extract of hyoscyamus, gr. iij 
Extract of nux vomica, gr. v 
Mass of mercury, gr. xv. 
Divide into 20 pills. Take 1 or 2 each night. 
The diet must be simple and fluids must be 
avoided. The recumbent posture should be kept 
upon deck. 
For the vomiting of sea-sickness 5 drops of a 4 
percent solution of cocain may be given 3 times 
daily; or- 
R. Chloroform, 
Tincture of nux 
vomica, 
each, gtt. x 
Compound tincture of 
lavender, 5 j 
Water, 5 x. 
A teaspoonful every hour until the vomiting 
and nausea cease, the bottle to be shaken 
each time a dose is given. 
Chloral, amyl nitrite, nitrogylcerin, and anti- 
pyrin may also be mentioned as useful. A spinal 
ice-bag may relieve the headache. 
From many years' experience, P. K. Taylor 
makes the following summary of the treatment: 
Rely chiefly, in nervous cases, on morphin and 
atropin, given by preference hypodermically; and 
on calomel and Rochelle salt for disturbed diges- 
tions. Bromocaffein will often relieve the head- 
ache, and cocain will sometimes be of great benefit 
in overcoming nausea, if given by the mouth. 
Avoid the bromids of potassium and sodium, as 
they do more harm than good, by upsetting the 
digestion. A belladonna plaster over the nape of 
the neck and a large capsicum plaster over the 
epigastrium will often be all that is needed to 
secure immunity from headache and nausea. If, 
when the ship is pitching much, a person instinc- 
tively holds his breath as he sinks to the hollow of 
each wave, insist on his "breaking step," so to 
speak. A determined effort to breathe regularly, 
and not in rhythm with the motion of the vessel, 
will quickly be successful in overcoming a muscular 
contraction of the diaphragm which, unchecked, 
would speedily lead to emesis. As regards diet, it is 
best to let patients choose for themselves to a great 
extent; that suited to one patient may not be toler- 
ated by another. Liquids should be restricted in 
amount. Solids, like toast or dry unsweetened 
biscuit, with a little iced champagne or brandy SEBORRHEA 
SELF-ABUSE 
to the adhesion of particles of dust to the 
skin. 
Seborrhcea sicca (dandruff) manifests itself as an 
accumulation of yellow or grayish scales, occurring 
upon the scalp or nonhairy regions. When the 
face is involved, the eyebrows and beard are 
usually affected first. 
Upon the scalp this condition is generally 
associated with falling of the hair (defluvium 
capillorum). 
The vernix caseosa is an intrauterine seborrhea, 
physiologic in character. The smegma proeputii 
is also a seborrhea. As a result of the decom- 
position of the secretion, balanitis sometimes 
develops 
Etiology.-The causation is obscure. The dis- 
ease occurs most frequently at the age of puberty. 
It is more common in women than in men, and in 
dark-complexioned persons than in blonds. It 
may be idiopathic, but is frequently met with in 
persons affected with tuberculosis, chlorosis, 
general debility, and gastrointestinal disorders. 
Diagnosis.-Oily seborrhea can scarcely be con- 
founded with any other affection. Seborrhcea sicca 
is to be distinguished from psoriasis, eczema, 
erythematous lupus, and ringworm. These are 
all characterized by redness and by more or less 
thickening. 
Pathology.-There is overaction of the sebaceous 
glands and of the sweat-glands, at times accom- 
panied by a slight degree of inflammation. Some 
observers consider the affection as microoganismal 
in character. 
Prognosis.-Favorable. Long-standing cases af- 
fecting the scalp lead to baldness. 
Treatment. Constitutional.-Tonics, such as 
arsenic, iron, strychnin, and quinin are often in- 
dicated. Duhring recommends calcium chlorid in 
doses of 1/10 to 1/5 grain. Gastrointestinal dis- 
orders should receive appropriate treatment. 
Local.-The indications are first to remove the 
crusts and scales, and then to use stimulating and 
astringent applications, with a view to favorably 
influencing the glandular secretions. Resorcin, 
sulphur, and salicylic acid are the three sovereign 
remedies. 
To soften adherent crusts upon the scalp: 
1^. Salicylic acid, gr. xx 
Olive oil, 3 iv. 
^This may be followed by the use of the tinc- 
ture of green soap to remove the epithelial 
debris. One of the following preparations may 
then be employed: 
I|. Resorcin, 3 jss 
Castor oil, rq xx 
Alcohol, 3 iv. 
(If an aqueous lotion is required, the castor 
oil and the alcohol may be replaced by 
glycerin and water.) 
1$. Fluidextract of pilcocarpin 3 j 
Tincture of cantharides, 3 ss 
Soap liniment, 3 ijss. 
Rub the scalp well with this lotion daily. 
I|. Sulphate of quinin, 3 jss 
Rectified spirit of wine, 3 iv 
Tincture of capsicum, 
Tincture of cantharides, 
Aromatic spirit of am- 
monia, 
each 5 ss 
Glycerin, 3 iv 
Water, enough to make O j. 
Apply locally. 
Upon nonhairy regions, or when there is but 
little hair upon the scalp, salves may be used: 
3- Precipitated sulphur, gr. xx to xxx 
Petrolatum, 3 ss 
Oil of bergamot, rq xx. 
Or-- 
I|. Salicylic acid, gr. x 
Petrolatum, 3 ss. 
Ammoniated mercury, calomel, carbolic acid, 
and other remedies are also employed, but the 
foregoing will be found to give the best results. 
For oily seborrhea use equal parts of alcohol and 
ether. 
Or- 
1$. Boric acid, gr. xxx to 3j 
Alcohol, 3 ij. 
Or- 
1$. Tannic acid, gr. xxx to 3j 
Alcohol, 
Water, 
each, o j 
SECALE.-See Ergot. 
SECTION.-See Abdominal Section, Cesa- 
rean Section. 
SECUNDINES.-The placenta, cord, and mem- 
branes expelled from the uterus after the birth of 
the child. For their management, see Labor. 
SEDATIVES.-Agents that exert a soothing 
influence on the system (or upon a part) by lessen- 
ing functional activity, depressing motility, and 
diminishing pain. General sedatives include the 
narcotics and anesthetics, while local sedatives 
include aconite, opium, ice, etc. Pulmonary seda- 
tives are hydrocyanic acid, veratrin, the nauseants, 
and the emetics. Spinal sedatives are physostigma, 
gelsemium, and potassium and sodium bromids. 
Stomachic sedatives include arsenic, bismuth, silver 
nitrate, and sodium bicarbonate. Vascular seda- 
tives are digitalis, tobacco, aconite, veratrum, and 
the emetics. Among nervous sedatives are potas- 
sium and sodium bromids, tobacco, lobelia, and the 
group of spinal depressants. Constitutional seda- 
tives overlap therapeutic divisions. The type is dis- 
tinctly narcotic and anesthetic. Of local sedatives, 
cold, in the form of ice or ether spray, deadens 
the sensibility of the skin. Aconite, opium, co- 
cain, belladonna, veratrin, and blisters soothe 
the sensory nerves and influence the circulation 
of the parts. The local sedatives are useful in 
rheumatic or neuralgic pain, in superficial inflam- 
mation, and to allay itching in prurigo, eczema, 
and skin affections. Diluted hydrocyanic acid, 
carbolic acid, chloroform, borax, and chloral 
hydrate are examples. 
SELF-ABUSE.-See Masturbation. SEMINAL EMISSIONS 
SENEGA 
SEMINAL EMISSIONS.-See Nocturnal Emis- 
sions. 
SEMINAL STAINS.-In all cases of alleged 
rape the underclothing of the victim should be 
carefully examined for seminal stains, which 
stiffen the fabric on which they are deposited in 
the same way that gum or albumin does. Moist- 
ened with warm water, seminal stains give off a 
characteristic odor. 
Lassaigne's test for semen is as follows: The 
seminal stain is moistened with a solution of lead 
oxid in liquor potassse and dried at 68° F. There 
is no yellow color developed, as would occur in 
albuminous fluids. However, semen diluted with 
an albuminous secretion develops a yellow color. 
The only positive proof, however, of semen is 
the discovery of spermatozoa by microscopic ex- 
amination. A drop of mucus from within the 
vagina may be placed upon the slide, or the 
stains may be dissolved and mounted. 
The old method of soaking and washing a 
fabric for seminal discharges often gives un- 
the particles removed. After soaking from 5 to 10 
minutes, the powdery mass will sink down through 
the water and rest upon the slide. The cover- 
glass may now be put on and the preparation 
examined. This latter method will serve well for 
semen on hairs. A circle of marine liquid glue 
run around the cover-glass will temporarily pre- 
serve the specimen. Carbolic acid or chloral hy- 
drate may be added to the water, as a preservative. 
A spermatozoon resembles somewhat the 
flagellate infusoria. It consists of an ovoid head 
tapering into a filamentary appendage, or tail, 
about 10 times as long as the head that, in fresh 
specimens, vibrates with astonishing rapidity. 
Spermatozoa vary in number and size, measuring, 
on an average, between 1/600 and 1/500 inch. 
The only living animalcule that might be mis- 
taken for a spermatozoon is the trichomonas 
vaginalis, occasionally found in the vaginal 
mucus of unclean females. It, however, has a 
large ciliated head and a shorter tail. 
The remarkable vitality of human spermatozoa 
is a well-recognized fact. The movements of the 
Spermatozoa.-(Landois.) 
1. Human (X 400), the head seen from the side. 2. On 
edge. k. Head. m. Middle piece: f. Tail. e. Ter- 
minal filament. 3. From the mouse. 4. From both- 
riocephalus latus. 5. From the deer. 6. From the 
mole. 7. From the green woodpecker. 8. From the 
black swan. 9. From a cross between a goldfinch and 
a canary. 10. From cobitis. 
Normal Semen.-(Webster.) 
spermatozoa may be observed for as long as 72 
hours at a suitable temperature. Piersol remarks 
that at a tempreature of 8.5° C. a few of the ele- 
ments showed movement after being kept for 
9 days. These facts have certain medicolegal 
bearings. 
SENEGA.-The dried root of Polygala senega 
(called also Seneca snakeroot), with properties 
due to a glucosid, senegin, which is identical with 
saponin, and closely allied to digitonin. Dose, 
10 to 30 grains. It is expectorant and diuretic; 
in large doses a gastrointestinal irritant, and is 
useful in bronchitis, asthenic pneumonia, asthma, 
etc. 
Preparations.-S. Fluidextractum. Dose, 10 to 
30 minims. S. Syrupus. Dose, 1 to 2 drams. 
Syrupus Scillae Compositus, contains 8 percent 
of senega. 
reliable results. The following rules for the 
microscopic examination of supposed seminal 
stains are offered by Hamlin: 
If the stain is upon any thin cotton, linen, silk, 
or woolen fabric, cut a piece about 1/8 inch square, 
lay it upon a slide previously moistened with a drop 
of water, and let it soak for half an hour or so, 
renewing the water from time to time as it evapo- 
rates; then, with two needles, unravel, or fray 
out the threads at the corners, put on the glass 
cover, press it down firmly, and submit to the 
microscope. If the fabric is of such thickness or 
nature that it cannot be examined in this way, 
fold it through the center of the stain, and with a 
sharp knife shave off the projecting edge thus 
made, catching upon a slide moistened with water SENNA 
SEPSIS 
SENNA.-The dried leaflets of Cassia acuti- 
folia and C. angustifolia. Senna contains an 
amorphous glucosid, cathartic acid; other con- 
stituents are sennapicrin, sennacrol, catharto- 
mannit, and chrysophanic acid. It is an excel- 
lent cathartic for children and infants. Senna 
acts chiefly on the small intestine, is not irritant 
in medicinal doses, and leaves no after-effect. 
However, it may cause hemorrhoids and hemor- 
rhagia, if long continued. Its odor and taste are 
disagreeable, particularly in infusion. The least 
disagreeable of its preparations are confection of 
senna and compound licorice powder. 
Preparations.-Fluidextractum S. Dose, 10 to 
60 minims. Syrupus S., has of the fluidextract 
25, oil of coriander 1/2, syrup to 100. Dose, 
1/2 to 2 drams. Confectio S., has of senna 10, 
cassia fistula 16, tamarind 10, prune 7, fig 12, 
sugar 55 1/2, oil of coriander 1/2, water to 100; 
is sold under the trade names Tamar Indien, 
and tropical fruit laxative. Dose, 1/2 to 2 
drams. Infusum S. Compositum, black draught, 
has of senna 6, manna 12, magnesium sulphate 
12, fennel 2, boiling water 80, cold water to 100. 
Dose, 2 to 6 ounces. Pulvis Glycyrrhizae Com- 
positus, compound licorice powder, contains 18 
percent of senna. Dose, 1/2 to 11/2 drams. 
See Glycyrrhiza. Syrupus Sarsaparillae Com- 
positus, compound syrup of sarsaparilla, contains 
1 1/2 percent of the fluidextract of senna. Dose, 
1 to 8 drams. See Sarsaparilla. 
SENSATION, DISORDERS.-These affect nerves 
of special or common sensibility, the lesion being 
either in the end-organ, in the afferent or efferent 
nerve, or in the ganglionic nerve-center. The 
sense of touch comprises the sensations of con- 
tact, pain, temperature, and muscular activity. 
Hyperesthesia, as commonly understood, ex- 
presses increased sensibility only to painful im- 
pressions, and is better called hyperalgesia. 
The affected skin is sometimes so tender that a 
light touch will produce more or less exquisite 
pain, and the hyperesthesia is usually associated 
with excess of sensibility to heat and cold and a 
diminution of the sensibility to touch proper. 
In gunshot wounds of the nerves it is seen in 
its most severe form. Hyperesthesia is observed 
in connection with peripheral and central diseases 
of the nervous system, and is an accompaniment 
of neuritis; it is usually expressed in heightened 
sensibility to temperature. 
Treatment.-The lesions causing the expression 
of perverted function must be discovered and 
treated. Local moist heat, as by fomentations 
or poultice; cold, by means of ice; dilute veratrin 
ointment, atropin ointment, or hypodermic 
injections of morphin, may mitigate the condition. 
Spongiopilin sprinkled with a liniment of chloro- 
form and belladonna (1:3), or equal parts of ether, 
volatile salt, laudanum, and cologne water, may 
be applied. Lint soaked in chloroform and covered 
with oiled silk, or rubbing the part with camphor- 
chloral and vaselin in equal parts, may suffice. 
Anesthesia may result from local abstraction of 
heat or from exposure to cold. Handling soda used 
in laundries and the various chemicals used in the 
arts may induce anesthesia. In herpes zoster the 
skin between the groups of vesicles is often 
anesthetic. In leprosy the senses of temperature 
and of pain are often abolished. Pressure upon 
sensory or mixed nerves, as by syphilitic tumors 
or other growths, may produce anesthesia. Sim- 
ple mechanic pressure will often excite an inflam- 
mation that is followed by anesthesia of the dis- 
tributive area. Trauma may cause pain followed 
by anesthesia. Severe nervous trophic disorder is 
usually associated with anesthesia. Before attacks 
of neuralgia the skin of the part surrounding 
is anesthetic; and during attacks of sciatica, and 
in cervicobrachial neuralgia, there is much diminu- 
tion of tactile sensibility. 
Approaching hemorrhage is often heralded by 
cutaneous anesthesia. Sudden and increasing 
numbness in one side of the face or in the limbs 
of one side may be shortly followed by apoplexy or 
coma. This anesthesia remains as a subjective 
feeling of numbness, but the extent bears no 
relation to the amount of motor paralysis. Re- 
covery proceeds downward, the fingers retaining 
slight anesthesia for some time after the arm 
is restored to normal sensation. Cerebral tumors, 
abscesses, or lesions of the spinal cord or of its 
membranes may give rise to cutaneous anesthesia. 
Cutaneous anesthesia affecting the soles of the 
feet occurs in tabes dorsalis. 
It is extremely important to remember that cuta- 
neous anesthesia connected with spinal disease 
is likely to result in bed sores and in trophic and 
vasomotor nerve affections. In peripheral neuritis 
anesthesia is of frequent occurrence. Aurse are 
often manifested by spots of local anesthesia. 
Loss of the sense of muscular activity is especi- 
ally noticeable in locomotor ataxia. It also occurs 
in general paresis, in hemiplegia, and in hysteria. 
As to diagnosis, the most important consideration 
is whether the causative lesion or disease is central 
or peripheral. 
Treatment.-This is bound up with the treat- 
ment of the underlying cause. When the sensory 
nerves fail to conduct impressions for some time 
after the lesions that caused the anesthesia have 
healed, electricity, derived from an induction 
machine or the negative pole of a continuous- 
current battery may be employed. Static elec- 
tricity is a valuable means of combating anesthesia 
of this kind. 
Paresthesia.-The varieties of this disorder are 
very numerous. Heat may be felt as cold; a 
faradic current (intolerable to the healthy) may 
be felt as cold; pricks or pinches may be felt only 
as touches; feelings of burning, numbness, tingling, 
creeping of ants, or actual numbness are other 
manifestations. The senses of contact, pain, 
and temperature may be in abeyance. Move- 
ments may be guided by the muscular sense aided 
slightly by sight, etc. 
SEPSIS.-Sepsis, or "blood poisoning," is a 
term used to designate sapremia, septic intoxica- 
tion, septicemia, and pyemia. The former two 
are due to the presence of toxins alone in the blood 
(toxemia), and the latter two to the presence of 
toxins and bacteria (bacteremia). These toxins SEPSIS 
SEPSIS 
and organisms may be of any variety, but in the 
following paragraphs the terms septic intoxication 
and septicemia are defined in their restricted sense 
as referring to pyogenic toxins and pyogenic 
bacteria. 
Sapremia is due to the absorption of the pro- 
ducts of putrefaction; hence, properly speaking, 
autointoxication from decomposing intestinal con- 
tents is sapremia. Saprophytic organisms are 
rarely found alone in surgical affections, conse- 
quently a pure form of sapremia is rarely seen. 
The best example is that due to the absorption of 
ptomains from'a decomposing placenta after child- 
birth, although a more or less pure form may be 
seen as the result of putrefaction of blood clots, 
wound secretions, or large tumors. Since sapre- 
mia is so frequently linked with other septic 
processes, and is clinically indistinguishable from 
septic intoxication, the term should be discarded. 
Septic intoxication (pyogenic toxemia) is due to 
the absorption of pyogenic toxins. The usual 
cause is pus under pressure, e. g., an unopened 
abscess or a badly drained, suppurating wound. 
As granulation tissue blocks lymphatic spaces, 
toxins are not readily absorbed from its surface, 
unless pressure be added; thus in a completely 
drained abscess there are no constitutional symp- 
toms; if the drainage be defective, however, or if 
the lymph spaces be opened by curettage, absorp- 
tion takes place. Chronic septic intoxication is 
hectic fever. 
The symptoms appear usually in from one to 
three days, and vary in degree according to the 
character and virulence of the toxin, the amount 
of absorption, and the resistance of the individual. 
They manifest themselves as fever, or pyrexia, 
which is a syndrome characterized by a rise in 
temperature (often preceded by a chill), quicken- 
ing of the pulse and respirations, headache, back- 
ache, diffuse muscular soreness, general weakness; 
by disordered secretions, causing dryness of the 
mouth, coating of the tongue, thirst, impaired 
appetite (sometimes vomiting), constipation or 
diarrhea, scanty high colored urine containing an 
excess of urea and urates, dryness of the skin or 
sweating; and by nervous disturbances varying 
from delirium to coma. There is a leukocytosis 
unless the intoxication is slight or overwhelming, 
but no organism in the blood. In the young and 
robust the symptoms are apt to be active (sthenic 
fever); in the debilitated, in the old, and even in 
the young (when protracted), they are apt to be of 
a low type and associated with marked exhaustion 
(typhoid state, asthenic or adynamic fever). The 
local symptoms are those of inflammation, and, if 
there be a wound, usually a copious and foul smell- 
ing discharge. 
Septicemia (pyogenic bacteremia) is septic intox- 
ication plus the presence of living pyogenic 
bacteria in the blood stream, and differs from 
pyemia only by the absence of secondary abscesses. 
The organisms gain entrance to the blood by the 
lymph vessels as the result of pressure in an 
abscess (secondary septicemia), or possibly in some 
cases pass directly into the open capillaries without 
the existence of suppuration (primary septicemia). 
Cryptogenic septicemia presents no wound or focus 
of suppuration; a forgotten needle puncture, or an 
abrasion on the skin or one of the mucous mem- 
branes may be responsible for these cases, which 
become fewer as the surgeon increases in experience 
and investigates with more care. Bacteria in the 
circulating blood are devoured by the leukocytes, 
or dissolved by the bacteriolytic action of the 
blood serum, thus terminating the process; or, if 
sufficiently numerous or virulent, and especially if 
the individual has not sufficient resistance to 
manufacture antibacterial serums or opsonins, 
they multiply, continue to elaborate toxins, and 
are distributed to various parts of the body, 
where they may cause secondary or metastatic 
abscesses (pyemia); some are eliminated by the 
excretory organs, and some are destroyed by the 
tissue cells. There is no specific microorganism of 
septicemia, any one of the pyogenic bacteria 
seemingly being capable of producing the condi- 
tion, although the streptococcus bears the worst 
reputation in this respect. 
The symptoms may be noticed a few hours after 
a wound, or not for several days. There is usually 
a chill, with a rapid rise in temperature to 104° or 
105° F.; the fever persists, being less in the morning 
and greater in the evening; in many cases there are 
violent chills at irregular periods, followed by 
high temperature and drenching sweats. The 
pulse increases in rapidity and decreases in tension. 
In severe cases the pulse rate reaches 150 or more, 
finally becoming so rapid and weak that it cannot 
be counted. There is often marked depression of 
the nervous system, the patient being stupid and 
quiet (typhoid state); or delirium, restlessness, 
picking at the bed clothes and twitching of the 
tendons; in either case coma precedes death. 
Although the respirations are quickened, signs of 
imperfect oxygenation of the blood are often seen 
in the face, which may be cyanotic. The tongue 
is dry, coated, red at the edges, pointed at the tip, 
and sordes are present upon its dorsum and upon 
the lips. There are loss of appetite, occasionally 
vomiting, often diarrhea. Petechise may appear 
in the skin and mucous membranes, and, owing to 
the disintegration of red blood cells, hematogenous 
jaundice may develop. The skin may present 
eruptions also in the form of vesicles or pustules, 
or simulating urticaria, measles, or scarlet fever. 
The urine is scanty, high colored, and contains 
albumin, toxins, and frequently bacteria; the 
spleen and often the liver are enlarged, and there 
may be leukocytosis. Bacteria may be discovered 
in the blood by cultural methods. 
The local manifestations vary from slight inflam- 
mation to the graver forms of cellulitis and are not 
always characteristic, although in many cases the 
wound discharges a thin pus, while the activity 
of the lymphatic vessels is shown by red lines of 
lymphangitis running to the nearest lymph glands, 
which are swollen and tender, or even suppurating. 
The veins about a suppurating wound may become 
inflamed, and blocked with coagulated blood 
(thrombophlebitis). Bacteria may invade and 
soften this thrombus, portions of which may be 
washed into the blood stream as emboli. SEPSIS 
SEPSIS 
Pyemia is septicemia plus secondary or metasta- 
tic abscesses, due to the bacteria lodging in various 
parts of the body, or to septic emboli the result of 
a thrombophlebitis; these abscesses may be found 
in any part of the body, but are most frequent in 
the bones, where bacteria are readily deposited 
from the capillaries owing to the slowly moving 
blood current, and in those organs which have 
terminal arteries, such as the brain, spleen, kidney, 
and lung. Emboli arising in the area drained 
by the portal vein lodge in the liver. Com- 
pared with preantiseptic days, pyemia is 
comparatively rare at the present time, but is 
especially prone to follow thrombophlebitis of 
the facial veins in infections in this neighbor- 
hood, thrombophlebitis of the lateral sinus the 
result of middle-ear disease, and pylephlebitis 
the result of inflammations about the rectum, 
appendix, etc. 
The symptoms are those of septicemia, plus the 
secondary abscesses, which usually appear during 
the second week; they are generally announced by 
an additional chill, but may develop insidiously, 
sometimes without even pain or tenderness, and 
they are commonly small and multiple. Pyemia 
may run its course in a few days (acute pyemia), 
or it may last a number of months (chronic 
pyemia). It is usually fatal, although recovery 
has occurred despite the presence of secondary 
abscesses in the internal organs. In pyemia there 
is said to be a characteristic sweet odor not unlike 
that of hay. 
Surgical scarlatina is the name given to the 
scarlet rash, probably the result of vasomotor 
disturbance, seen in cases of sepsis. True scarla- 
tina may, however, occur after operations and 
accidental wounds, especially in children. Since 
the period of incubation is shorter than in the non- 
surgical form, it may be that the microorganism 
of scarlet fever enters through the wound. Scarlet 
rashes may occur likewise from the absorption of 
ether, bichlorid of mercury, carbolic acid, and 
iodoform. 
The diagnosis of sepsis is made by finding the 
causative lesion and excluding other febrile mala- 
dies. The causative lesion is sometimes difficult to 
locate, particularly in the so-called cryptogenic or 
spontaneous form, in which it may be necessary to 
review the entire body before finding the source of 
infection. Regions especially liable to be over- 
looked are the ear, teeth, throat, urethra, rectum, 
in women the pelvic organs, and in children the 
bones, particularly the tibia. An insignificant 
wound that has healed may be the starting point 
of even the gravest forms of sepsis, and, on the 
other hand, a wound, even if suppurating, may be 
complicated by other forms of fever. Here it 
should be noted that tonsillitis may be the cause, 
and pneumonia, endocarditis, etc., the result of 
sepsis. The exclusion of aseptic fever is made by 
the healthy appearance of the wound and the brief 
duration of the fever, of autointoxication by 
stimulating the excretory organs. When there is 
marked depression of the nervous system and 
general exhaustion, typhoid fever (Widal reaction, 
leukopenia) and miliary tuberculosis may be 
simulated, while the occurrence of chills is often 
wrongly interpreted as malaria; in the last a blood 
examination will reveal the presence of malarial 
parasites. The occurrence of skin rashes, par- 
ticularly in children, will bring up the question of 
the acute exanthemata, especially measles and 
scarlet fever. The form of sepsis is toxemia 
(sapremia or septic intoxication) if, in the pres- 
ence of an inflamed or suppurating wound, the 
symptoms promptly subside after thorough drain- 
age and disinfection. If the wound does not show 
evidences of irritation, the constitutional disturb- 
ance may be due to septicemia, but is more prob- 
ably the result of some medical complication. 
The continuation of fever after the opening of an 
abscess or wound, excluding medical complications, 
usually means inefficient drainage, that is, a con- 
tinuation of the septic intoxication, or, if the 
wound is perfectly drained, septicemia. In the 
latter instance, the absorption of bacteria may 
be evidenced by red and tender lymph vessels 
coursing along the surface and ending in inflamed 
lymph glands; the constitutional symptoms are 
more severe than in septic intoxication, and chills 
are more likely to occur. A positive diagnosis can 
be made only by recovery of the organisms from 
the blood stream, or from the excretions, particu- 
larly the urine. Leukocytosis occurs in all forms 
of sepsis, as does also iodophilia. The diagnosis of 
pyemia is made by the metastatic abscesses, which, 
when superficially situated, are easily detected; 
but when deeply seated in the viscera, they are apt 
to be small and numerous, and often their presence 
can only be suspected. 
The treatment of sepsis is first prophylaxis. All 
wounds accidentally received should be carefully 
disinfected and the most scrupulous antiseptic or 
aseptic precautions taken during operations and 
the delivery of pregnant women. After labor the 
placenta should be carefully inspected to make 
sure that none of it has been left behind, after mis- 
carriage curettage of the uterus is often done with 
the same end in view. It is important before 
operations also to increase the resistance of the 
patient by suitable treatment. 
The local treatment is that of the causative 
lesion, viz., inflammation, suppuration, gangrene, 
etc. Uncomplicated sapremia or septic intoxica- 
tion rapidly subsides if the local cause be found and 
removed. If the symptoms continue, all the 
putrefying material has not been removed, drain- 
age is not efficient, or bacteria are elaborating 
toxins in the blood stream (septicemia). In the 
last the outlook is always grave, although, as has 
already been indicated, destruction of bacteria and 
recovery may follow. In pyemia secondary 
abscesses should be incised and drained, but un- 
fortunately, in the viscera, this is often impracti- 
cable owing to their multiplicity. An accessible 
vein, the subject of thrombophlebitis, should be 
excised, or (e. g., lateral sinus) opened, the clot 
removed, and the cavity packed with gauze; in 
order to prevent the further dissemination of 
septic emboli, the vein may be tied between the 
thrombus and the heart; in the extremities ampu- 
tation may be required. SEPSIS 
SERUM THERAPY 
The general treatment is (1) specific, (2) elimina- 
tive, (3) symptomatic. (1) Specific treatment 
aims to destroy bacteria in the blood stream or to 
neutralize their toxins. Unfortunately, pyogenic 
bacteria in the blood stream are inaccessible. The 
injection of antiseptics into the circulation, in 
sufficient strength to be of value, is dangerous. 
Antistreptococcic serum, which at first seemed to 
give much promise, has been found to be ineffect- 
ual; it may, however, be employed in 10 c.c. doses 
repeated every 3 or 4 hours, particularly if bacte- 
riological examinations prove the infection to be 
due to streptococci; like diphtheria antitoxin, 
which, too, has been used in septic conditions 
without success, it may produce erythematous or 
urticarial eruptions and pains in the joints, and 
several cases have been reported in which sudden 
death followed the injection of the serum. Vac- 
cine treatment is still on trial. Quinin, iron, and 
large doses of alcohol (whisky or brandy) are re- 
garded by many as almost specific in septic pro- 
cesses. (2) The most efficient means of combat- 
ting sepsis is by elimination of the microorganisms 
and their products. Purgation, especially by 
calomel and salines, lowers the blood pressure, 
drains off toxins through the bowel, and clears the 
intestinal tract of material which may be absorbed 
and aggravate the symptoms. If nature has 
anticipated the physician by the production of a 
diarrhea, such should not be checked unless 
excessive. Diuretics, such as calomel, caffeine, 
squill, sweet spirit of niter, acetate of potassium, 
and large quantities of water by mouth or rectum, 
are of great value in removing toxins from the 
blood, in lowering temperature, and in reducing 
blood pressure. When both the stomach and 
rectum are irritable, the same principle may be 
utilized by injecting salt solution into the sub- 
cutaneous tissues, or, exceptionally, directly into a 
vein. Diaphoretics are not often used, as when 
they are indicated in septic conditions profuse 
sweats are generally present. Venesection is occa- 
sionally employed to lessen the amount of toxin 
in the circulating blood, especially when followed 
by the intravenous injection of salt solution. It 
should never be used in infancy, old age, or in the 
debilitated. (3) Symptomatic treatment depends 
upon the indications. Rest in bed, predigested 
liquid food, and proper nursing are always required 
in severe cases of sepsis. The best anodyne, if the 
condition is to last but a short time, is opium or one 
of its derivatives. In most surgical inflammations 
pain severe enough to prevent sleep calls for in- 
cision and drainage of the affected part. Nervous- 
ness is best met by the bromids, and sleeplessness 
not caused by pain, by sulphonal or trional. The 
cold-tar products and chloral, because of their de- 
pressing effects, are usually to be avoided. The 
best antipyretic is an ice cap on the head, and 
general sponging with ice water, or equal parts of 
alcohol and water; drugs should be rarely em- 
ployed. Persistent fever usually means that fur- 
ther search for the source of infection, with proper 
incisions, disinfection, and drainage, should be 
carried out. In many cases stimulants, such as 
alcohol, strychnin, ammonium carbonate, and 
digitalis will be needed. (Stewart.) See Suppura- 
tion; Colon Bacillus Infection. 
SEPTICEMIA.-See Sepsis. 
SEPTIC INTOXICATION.-See Sepsis. 
SEPTUM, NASAL.-See Nose (Deformities), 
Rhinitis (Chronic). 
SEQUESTROTOMY.-See Bone (Disease). 
SERPENTARIA (Snakeroot).-The roots of 
Aristolochia serpentaria and A. reticulata. Its 
properties are due to a volatile oil, a camphor-resin, 
and a bitter extractive. Serpentaria is a stimu- 
lant expectorant and a tonic; also a cardiac stimu- 
lant, a diaphoretic, diuretic, emmenagog, aphro- 
disiac, and somewhat of an antiperiodic. Its taste 
is warm and pungent, its odor characteristic. Dose, 
10 to 30 grains. Large doses are irritant, causing 
nausea and vomiting, vertigo and headache, colic, 
borborygmi, rectal tenesmus, flatulent distention, 
and frequent but not watery stools. The irritant 
action seems to produce gas rather than fluid. 
Pruritus ani and hemorrhoids are occasionally 
caused by its use. Serpentaria is chiefly employed 
as a vehicle for other stimulant drugs. 
Preparations.-S., Fluidextract. Dose, 10 to 
30 minims. S., Tinct., 20 percent in strength. 
Dose, 1/2 to 2 drams. Compound Tincture of 
Cinchona has 2 percent of serpentaria. 
SERUM DISEASE.-See Serum Therapy. 
SERUM THERAPY. Definition.-The word 
serum is used here in the sense of blood serum 
obtained from an animal which has been ren- 
dered actively immune to some bacterial dis- 
ease by injecting it with living or killed bacteria 
or with bacterial toxins. Convalescent serum, 
which will receive brief consideration, is blood 
serum from a patient who, at the time the serum 
is drawn, is recovering or has recovered from the 
disease for the cure or prevention of which the 
serum is to be used. Such a patient is therefore 
in a condition analogous to that of an animal 
which is going through a course of immunizing 
inoculations. It is to be observed that the 
administration of a serum for the prevention or 
cure of a disease acts by producing a passive 
immunity in the injected individual. 
Mode of Action.-The use of protective and 
curative sera is based on the theories of immunity 
as elaborated by Metchnikoff, Ehrlich and others; 
or rather, on the general theory of immunity ac- 
cepted at the present time, which combines the 
essentials of Ehrlich's lateral chain theory and 
Metchnikoff's doctrine of phagocytosis. Metchni- 
koff held that bacteria, and other nonbacterial 
causes of disease, are devoured by certain cells in 
the body, notably the leukocytes in the blood, in 
the same way as the ameba devours the minute 
organisms on which it feeds. This process he 
termed "phagocytosis," and that it actually takes 
place can be demonstrated under the microscope. 
It was soon discovered, however, by Buchner, 
Nuttal and others that in many cases of immunity 
there is no demonstrable phagocytosis and that 
the body juices alone, unaided by cells, possess 
the power of destroying bacteria bacteriolysis'). 
This doctrine of the bacteriolytic power of the 
blood serum gradually overshadowed the older SERUM THERAPY 
idea of phagocytosis and, with certain additions 
by various investigators, forms the basis of medi- 
cal thought on the subject of immunity at the 
present time. Metchnikoff himself modified his 
original doctrine by assuming the production of 
enzymes within the leukocytes and their libera- 
tion into circulating blood. Later Sir Almroth 
Wright propounded his theory of "opsonins," 
substances contained in the blood serum which 
influence bacteria in such a way as to render them 
susceptible to phagocytosis. According toWright's 
theory, the serum of every normal individual 
is endowed with this "opsonic power" against all 
bacteria-some more, some less-and, moreover, 
this opsonic power, or "opsonic index," as it is 
termed, can be influenced by introducing killed 
bacteria {"vaccines") into the circulation. It is 
now generally held that enzymes, opsonins, alexins, 
or whatever the protective substance in the blood 
serum may be called, are capable not only of 
destroying pathogenic bacteria, but also of neu- 
tralizing bacterial toxins. The cells which are be- 
lieved to possess this bacteriolytic power in thehigh- 
est degree are the polymorphonuclear leukocytes. 
Immunity, therefore, does not always depend upon 
the same biologic reactions: it may result from the 
incorporation and destruction of bacteria by body 
cells {phagocytosis') or from the destructive action 
of body juices-blood serum, lymph, cerebro- 
spinal fluid-into which the cellular enzymes have 
been discharged {bacteriolysis); or, when the dis- 
ease is due to the products of bacteria, such as the 
toxins of diphtheria and tetanus, snake venom, 
and the like, immunity may depend upon the 
neutralizing action on the chemical bacterial 
poison of protective substances {antitoxin) con- 
tained in the blood. 
Ehrlich's lateral chain theory of immunity 
deserves more extended description. It applies 
to the mechanism of cellular nutrition in general, 
and its application to immunity represents only a 
restricted phase of all the phenomena with which 
it deals. According to Ehrlich, the cell is equipped 
with large numbers of lateral chains, or groups of 
combining molecules, an illustration borrowed 
from the structural diagrams of organic chemistry. 
These lateral chains are supposed to have specific 
combining affinities, and it is through the combina- 
tion of special molecular groups with appropriate 
groups in the tissue juices that cellular nutrition 
and metabolism are maintained. Thus, there is 
no intrinsic difference between the mechanism of 
normal nutrition and the mechanism of intoxica- 
tion, clinically manifested as disease. As the needs 
of different cells vary, so their molecular side chains 
vary; and certain body cells form combinations 
with molecular groups in the tissue juices that 
have no affinity for other body cells. Again, all 
the cells of one species of animal may have affini- 
ties for certain molecular groups (poisons) which, 
on the other hand, are quite incapable of combin- 
ing with the body cells of a different species; in 
such a case the animal, having no suitable side 
chains, is immune to that particular poison and 
to the disease which it causes. These lateral chains 
are called "receptors," and the appropriate molec- 
SERUM THERAPY 
ular group in the pabulum with which they com- 
bine is known as a "haptophore." Cell nutrition 
or, on the other hand, poisoning of the cells, is 
effected through a union of receptors with hapto- 
phores. In bacterial infections the ability of the 
bacteria or their toxins to exert a deleterious effect 
upon the body depends upon their ability to attach 
themselves to these cell receptors. Such deleter- 
ious action may be due merely to the fact that the 
foreign haptophores supply no useful material and 
displace the pabulum required by the cell; or, as in 
the case of bacterial invasion, the haptophores 
may exert a direct toxic action on the body cells. 
The toxin molecules are conceived to be composed 
of two separate groups, of which one, the "hapto- 
phorous" group, is for the purpose of fixation, 
while the toxic function resides in the poisonous 
or " toxophorous" group; the body cells hav- 
ing appropriate receptors-"haptophilous" and 
" toxophilous"-through which the respective 
functions of the toxin are accomplished. Until 
the haptophore of the toxin has combined with the 
haptophile of the cell, the toxophore cannot attack 
the cell body. 
The lateral chain theory affords the most 
plausible explanation of acquired or active immun- 
ity, a condition brought about by the repeated 
introduction of minute, nonfatal doses of poison 
into the circulation. The more frequently the 
administration takes *place, and the greater the 
quantity of poison administered, the more tolerant 
the animal becomes to the poison or the disease 
which it produces. This phenomenon is explained 
by assuming that the lateral chains or receptors 
are capable of regeneration for the purpose of sup- 
plying the needs of the cell; and if the stimulation 
is continued long enough, so many side chains or 
receptors are produced that they are finally cast 
off by the cell and circulate free in the blood in the 
form of "antibodies" (antitoxin). These anti- 
bodies meet and combine with the toxin molecules, 
neutralizing their toxic action, and so protecting 
the body cells. When a dose of diphtheria anti- 
toxin is injected into a patient, enormous numbers 
of antibodies are suddenly set free in the circula- 
tion and immediately combine with and neutralize 
the diphtheria toxin present in the body, and thus 
produce their protective and curative effect. 
Sera are of two kinds: (1) antitoxic and (2) 
antimicrobic or bacteriolytic. The mechanism of 
bacteriolysis, like that of hemolysis and cytolysis 
in general, requires the consideration of certain 
additional phenomena of immunity, and certain 
theories to which observation of these phenomena 
has given rise. Buchner's original observation 
that the body juices have the power of killing and 
dissolving bacteria by means of a substance which 
he called "alexin" has been confirmed by sub- 
sequent workers. By whatever name it may be 
called-and it is now generally spoken of as " com- 
plement"-this bacteriolytic substance is con- 
tained in normal blood and is practically inde- 
structible. Whether there are specific comple- 
ments for different cells-blood cells, bacterial 
cells, etc.-has not been entirely established, but 
is probable; the general belief now is that comple- SERUM THERAPY 
SERUM THERAPY 
ments, as well as amboceptors, are specific. The 
complement acts indirectly, like a ferment; thus 
rennet acts upon caseinogen only in the presence of 
calcium salts; and, in like manner, the complement, 
whether universal or specific, acts upon bacteria, 
blood corpuscles or other cells, only in the pres- 
ence of another substance-the "amboceptor" or 
"immune body." This immune body is variable 
and specific. Various immune bodies are found 
in the normal blood of many animals, and different 
kinds of blood vary greatly in the number and 
kind of immune bodies which they normally con- 
tain. Immune bodies, which may be regarded as 
identical with the receptors of the body cells, can 
readily be made to increase by artificial stimula- 
tion. 
Method of Preparation.-The general method 
of producing sera or antitoxins as they are loosely 
called, is as follows: The animal usually selected 
(on account of the large quantity of serum which 
it yields) is the horse; although the quantity of 
active antitoxin produced by individual animals 
is extremely variable. Moreover, quantity is not 
the only factor to be considered; and it may well 
be that, in the future, as the method is further 
developed, certain animals will be found to be bet- 
ter adapted for the production of one kind of 
serum than another. As an example, the ram is 
found to be the most suitable animal for the pro- 
duction of antigonococcus serum. The animal 
having been carefully selected with reference to its 
general health and freedom from communicable 
disease, especially tetanus, increasing doses of 
toxic bouillon of known strength, obtained from a 
culture of the specific bacillus against which the 
serum is to be employed, are injected at intervals 
varying from a few days to a week, the dose of 
toxin being increased as rapidly as possible with- 
out producing obvious injury to the animal. The 
time necessary for the production of immunity 
varies in different animals and with different bac- 
teria; it may be only a few months or very much 
longer. When a test of the blood shows that it 
contains sufficient antitoxin, the animal's jugular 
vein is tapped with a trocar, and as much blood as 
can be withdrawn without doing harm is received 
into a sterile container, permitted to coagulate, 
and the serum drawn off with a pipet. The serum 
is put up in sealed glass tubes under aseptic pre- 
cautions, after the addition of an antiseptic to 
increase its keeping qualities. 
Standardization.-Since the immunizing power 
of a serum is a variable quantity, it is important 
to determine the strength of the individual out- 
put, a process known as standardization. The 
" immunizing unit" is that quantity of serum which 
will protect a given animal, usually a guinea-pig 
weighing 300 grams, against a certain arbitrarily 
assumed quantity of toxin. Thus, in the case of 
diphtheria antitoxin, which may be taken as a 
typical example, a unit is that quantity of anti- 
toxin which will protect a 300 gram guinea-pig 
against 100 times the fatal dose of diphtheria 
toxin. Some manufacturers indicate the strength 
of the serum in relation to a given number of grams 
of guinea-pig. In several of the newer sera, how- 
ever, scientific standardization is impossible, and 
the dose is purely empiric, as in the case of anti- 
gonococcus and antistreptococcus serum. 
Administration.-Therapeutic serum may be 
injected hypodermically, deep into the muscles, 
intravenously, intradurally, or applied as dusting 
powders to open wounds. Of these methods, the 
hypodermic route is the one most frequently 
employed, except with antitetanic and antimen- 
ingitic serum. The subscapular region, the abdom- 
inal wall, or the inner aspects of the thighs are 
usually selected for subcutaneous or intramuscu- 
lar injections, and the usual antiseptic and aseptic 
precautions necessary with hypodermoclysis or 
intravenous infusion must of course be observed. 
Administration by the mouth has been tried, but 
appears to be ineffective. Since, so far as known, 
therapeutic sera are absolutely specific, an exact 
bacteriologic diagnosis should precede the admin- 
istration, whenever the nature of the disease makes 
this possible. 
Serum Intoxication.-The use of therapeutic 
serum is sometimes attended by certain unpleas- 
ant and even alarming symptoms, due probably 
to the introduction of a foreign serum and not to 
any specific action of the antibodies contained. 
It is probable, therefore, that the magnitude of 
the dose injected bears no relation to the occur- 
rence or severity of such by-effects. In about 20 
percent of all the cases in man the injection of serum 
produces a temporary intoxication in which any 
or all of the following symptoms may be present: 
fever, itching, urticaria and other skin eruptions, 
glandular enlargements, pains in the joints, edema 
and albuminuria. These symptoms develop in 
from 8 to 12 days after the injection. They 
occur after the first injection, whereas anaphy- 
laxis (in animals) manifests itself only after the 
second injection. Previous injections, however, 
predispose an individual to "serum intoxication" 
or "serum disease," as it is called, in direct pro- 
portion to the number of previous injections. The 
symptoms of serum disease subside in a short 
time and leave no bad effects. 
Anaphylaxis.-Serum disease is not to be con- 
founded with the condition called "anaphylaxis" 
or " allergie." If a guinea-pig is injected with a 
small quantity of horse serum and, after the expira- 
tion of a certain interval, is again injected with 
horse serum, the result will probably be fatal. 
The first injection has sensitized the animal in 
such a way as to render it abnormally susceptible 
to the second injection. Other proteid substances, 
such as egg albumen, have the same effect as nor- 
mal serum. Anaphylaxis may be defined as a 
hypersensitive condition induced by the injection 
of normal, foreign horse serum or other proteid 
substance. The hypersensitive condition is mani- 
fested after the second injection, separated from 
the first injection by a certain interval which may 
be called the period of incubation, and death may 
sometimes result. The first injection itself produces 
no symptoms, and, as stated, the condition is not 
identical with serum intoxication, which develops 
after a first injection of serum. The very rare 
instances of sudden death following a single injec- SERUM THERAPY 
tion of diphtheria antitoxin are sometimes attri- 
buted to anaphylaxis, but no sufficient proof in 
support of this explanation has been furnished. 
The extreme rarity of the accident-about one 
case in 400,000 injected with diphtheria antitoxin 
-would appear to indicate that death is due to 
some extrinsic cause, such as fright or congenital 
hypersensitiveness to the trauma of the injection, 
rather than to any toxic property of the serum, or 
else to some as yet undiscovered biologic reaction. 
Diphtheria antitoxin, even in massive doses, is in 
itself absolutely harmless. 
Antidiphtheritic Serum.-See Diphtheria Anti- 
toxin. 
has been reduced about one-half, or from 80 or 90 
percent to 40 or 45 percent. 
Prophylaxis.-While the curative effect of 
tetanus antitoxin falls below that of antidiph- 
theritic serum, the immunizing action of a prophy- 
lactic dose, which is given as 5 c.c. or 1500 units, 
appears to be absolute. For this purpose the 
dried powder is particularly well adapted, and 
should be used in the case of all suspicious wounds 
that have been exposed to infection with dust, 
dirt, garden earth, manure, or any other suspi- 
cious substance. 
SERUM THERAPY 
Antitetanic Serum. Tetanus Antitoxin. 
Antivenins. 
The serum, like diphtheria antitoxin, is a true 
antitoxin and is obtained in a similar way from the 
blood of horses immunized against the toxins of 
the tetanus bacillus. It is marketed both in the 
liquid form and as a powder. Tetanus antitoxin 
is specific, and the only indication for its use is 
tetanus. 
Strength and Dosage.-The official unit adopted 
by the United States Public Health and Marine 
Hospital Service is "ten timso the least quantity 
of antitetanic serum necessary to save the life of a 
35CUgram guinea-pig for 96 hours against the 
official test dose of a standard toxin furnished 
by the Hygienic Laboratory of the United States 
Public Health and Marine Hospital Service." 
Each vial or syringe of tetanus antitoxin made by 
the American houses contains from 1500 to 5000 
units, without regard to the volume of serum, 
which is about 20 c.c. The unit value per cubic 
centimeter varies from 150 to 600 units. 
Any directions with regard to dosage must be 
purely empiric, the only hope of effecting a cure 
lies in the early and vigorous use of the serum. 
From one to four vials, each containing 20 c.c., 
should be given as an initial dose, and the injec- 
tion repeated every six hours until a reaction is 
noted; enormous quantities have been employed 
in desperate cases with apparently curative 
effects. 
Administration.-Five modes of administering 
tetanus antitoxin are available: by subcutaneous 
injection; intravenously; intraneurally-into the 
nerve leading from the infected area; into the 
spinal canal, or under the dura through a trephine 
opening; and by dusting the pulverized serum on 
the infected wound. Of these methods, the sub- 
cutaneous is the one most frequently employed; 
it is easier to carry out, is less painful to the 
patient, and is apparently as effective as other 
routes. Powdered serum is used only prophy- 
lactically on suspicious wounds. 
Prognosis.-The most important factor is the 
length of the period of incubation; few cases hav- 
ing a period of less than 7 days recover under any 
treatment. Subacute and chronic cases, and 
cases in which the period of incubation is longer 
than a week, give a better prognosis. Numerous 
recoveries with the antitoxin treatment have been 
reported, however, and the remedy should be 
tried in every case. It is estimated that since the 
introduction of the serum the mortality of tetanus 
Antivenin is the serum of an animal, usually a 
sheep or goat, immunized against the venom of 
some poisonous snake. As antivenins are specific, 
they are active only against the venom of the 
particular species of snake used in immunizing the 
animal from which the antivenin is obtained. 
Snake venoms contain three toxic principles- 
neurotoxins, hemorrhagins and fibrin ferments. 
Broadly speaking, neurotoxins form the most 
important constituent in the venom of the cobra 
and other Indian and African venomous species; 
while the venom of crotaline snakes, such as the 
American rattle-snake, copperhead and moccasin 
snake, produces its poisonous effects chiefly 
through the hemorrhagins it contains. The venom 
of the Australian serpents contains all three con- 
stituents in fairly equal quantities. The neuro- 
toxins of the colubrine serpents cause death 
through paralysis of the respiratory center, and the 
bite of these snakes is far more dangerous than 
that of the crotaline species, which, by virtue of 
the contained hemorrhagins, produces extensive 
local destruction, but rarely causes death unless 
through secondary septicemia. The specificity 
of the various antivenins is now definitely estab- 
lished and has an important bearing on their 
therapeutic use. Thus, the antineurotoxin of 
cobra antivenin (Calmette, Lamb) cannot neutral- 
ize other toxic constituents of snake venom, nor in 
fact any other neurotoxin, but cobra neurotoxin. 
The antihemorrhagin of crotalus antivenin (Flex- 
ner and Noguchi, McFarland) is capable of neu- 
tralizing only the corresponding hemorrhagins, 
and in the same way the fibrin ferment of daboia 
venom, and its hemolytic action, are not affected 
by the antifibrin ferments of other antivenins. 
The following varieties of antivenin are available: 
Cobra antivenin (Calmette, Lamb). 
Crotalus antivenin (Flexner and Noguchi, 
McFarland). 
Moccasin antivenin (Noguchi). 
Lachesis antivenin (manufactured and used in 
Brazil). 
Crotalus terrificus antivenin (Brazil). 
Trimeresurus antivenin (Kitashima, Ishizaka). 
Daboia Antivenin (Lamb). 
Calmette and McFarland use several venoms 
in the preparation of their sera, which are therefore 
polyvalent, but their action against venoms other 
than that of the cobra and crotalus is feeble. 
Standardization.-The strength of antivenins is 
determined by injecting animals with a mixture of SERUM THERAPY 
SERUM THERAPY 
venom and antivenin, different laboratory animals 
being selected by various investigators. In the 
case of daboia venom, which cannot be tested on 
animals on account of the powerful fibrin ferments 
contained (hemolysis) standardization is effected 
by using a mixture of venom and antivenin in 
vitro, or by observing the anticoagulating power 
on the citrated blood plasma in vitro. 
According to Calmette's method a standard 
solution of venom is prepared, the unit of which is 
based on the quantity of venom necessary to kill a 
rabbit of two kilograms in twenty minutes by 
injection into the marginal vein of the ear. This 
quantity corresponds on an average to 2 milli- 
grams of cobra venom and to 4 milligrams of 
rattlesnake venom weighed dry. An antivenin, 
to be sufficiently active for therapeutic use, must 
be protective in the minimum dose of 2 c.c 
when injected into the ear vein 15 minutes before 
the injection of the venom. 
Dosage.-Theoretically, the dose should be that 
quantity of antivenin which neutralizes the maxi- 
mum quantity of venom that a snake can inject. 
Thus, from 200 to 350 c.c. of the cobra antivenin 
prepared by Lamb, and from 100 to 150 c.c. of 
Flexner and Noguchi crotalus (rattle-snake) anti- 
venin are required to neutralize the maximum 
quantity of venom that a cobra or rattle-snake is 
able to inject at one bite under the most favorable 
conditions. Practically, however, the natural 
resistance of man to snake venom and the circum- 
stance that the maximum quantity of venom is not 
invariably injected greatly influence the size of the 
necessary dose of antivenin. The minimum fatal 
dose of different venoms for man has been approxi- 
mately estimated from animal experiments, and it 
may be stated that the fatal dose of crotalus venom 
is from 0.15 to 0.20 gram (Noguchi), that of cobra 
venom from 0.015 to 0.0175 gram (Lamb). As 
it is only necessary to neutralize the excess of 
venom over the human tolerance, the administra- 
tion of a few cubic centimeters of antivenin may 
suffice to prevent a fatal issue. The bite of the 
rattle-snake, especially, is rarely fatal. The 
average dose is given as 10 c.c., repeated as often as 
may seem necessary. 
Administration.-Antivenins are administeied 
intravenously or into the muscles. In case of 
rattle-snake bites it is advised that the serum be 
injected both intravenously and around the 
wound (Noguchi). The specificity of the anti- 
venin must always be respected, and early admin- 
istration is an important factor in the success of 
the treatment. 
At best, the administration of antivenin must be 
regarded only as an adjunct to other well estab- 
lished procedures, which are summarized by Cal- 
mette as follows: (1) If possible, place an elastic 
ligature tightly above the seat of the bite, so as to 
prevent absorption of the venom. (2) Inject 
immediately into the seat of innoculation and in 
several places about the bite and at no great dis- 
tance from it, from 20 to 30 c.c. of a fresh 1 per- 
cent solution of chlorid of gold or calcium. (3) 
Remove the ligature and wash the part with a 
large quantity of a sodium hypochlorite or cal- 
cium chlorid solution. (4) As soon as possible 
administer to the patient, by subcutaneous injec- 
tion, 20,000 units of antivenin. 
Antistreptococcus Serum. 
An antimicrobic and bacteriolytic serum ob- 
tained from animals immunized against strepto- 
cocci obtained from various sources. Most anti- 
streptococcic or " streptolytic " sera are poly- 
valent, and some are " composite," i. e., they contain 
diphtheria antitoxin as well as streptococcus anti- 
bodies, being obtained from animals previously 
immunized to diphtheria toxin. 
Preparation.-Most of the preparations on the 
market are polyvalent. In some cases humanized 
strains of streptococci are employed in immunizing 
the animals: in others, cultures which have been 
passed through animals to increase their virulence; 
sometimes both human and animal strains are 
used. 
One of the earliest antistreptococcic sera was 
prepared by Marmorek by the immunization of 
ponies against increasing quantities of living cul- 
tures of streptococci, the virulence of which was 
previously increased by passage through rabbits. 
Marmorek recommended the serum especially in 
erysipelas, streptococcus suppuration, puerperal 
infection and scarlet fever. Aronson's anti- 
streptococcus serum is prepared by immunizing 
horses against streptococci, cultivated from scar- 
let fever patients. The dose recommended in 
scarlet fever is from 20 to 100 c.c. Moser's anti- 
scarlatinal serum, for the preparation of which 
streptococci were isolated from the hearts of 
patients who had died of scarlet fever, for a time 
enjoyed some reputation in the treatment of that 
disease. Menzer applied the principle of serum 
therapy to rheumatic arthritis and prepared a 
serum with streptococci obtained from the tonsils 
of rheumatic patients. 
Some of the methods devised by these investi- 
gators have been adopted by manufacturing 
houses, and sera bearing their names are found on 
the market. These sera are labeled "polyvalent," 
"erysipelas," "scarlet fever," "rheumatism," etc., 
according to the source from which the bacteria 
used in their preparation are obtained and the 
purpose for which they are especially intended. 
Dosage.-As there is no method of determining 
the strength of the various antistreptococcic sera, 
the dose is purely empiric and it is customary to 
inject subcutaneously from 10 to 20 c.c., and 
repeat the dose according to indications. As the 
remedy appears to be free from any harmful by- 
effects, it may be used fearlessly in very much 
larger quantities. 
Indications.-Antistreptococcic serum has been 
used principally in erysipelas, puerperal sepsis, 
local streptococcus infections, ulcerative endocarditis, 
and general septicemia when living streptococci 
are demonstrated in the blood. Special sera, 
such as Aronson's and Moser's, have been used and 
warmly recommended by some authors in the 
treatment of scarlet fever. The serum treatment 
of rheumatism also has its enthusiastic advocates. 
Finally there are reports in the literature of the SERUM THERAPY 
SERUM THERAPY 
successful use of various antistreptococcic or 
streptolytic sera in the treatment of such condi- 
tions as gangrenous stomatitis, smallpox, various 
forms of angina, and pernicious anemia. 
Testimony in regard to the value of this remedy 
is conflicting, and while good results have undoubt- 
edly followed its use in many instances, it does not 
at the present time enjoy a very high reputation. 
If it were practicable to use autogenous serum, as 
in the case of vaccine or bacterin therapy, so as to 
make certain of the identity of the organism caus- 
ing the disease with that used in preparing the 
serum, it is probable that the results would be 
more uniformly satisfactory. This is, however, 
for obvious reasons impossible. In a report on 
the preparations now on the American market, 
Hektoen, Weaver and Tunnicliffe state that 
"attempts to obtain protective and curative 
affects from the injection of antistreptococcic 
serums in rabbits, guinea-pigs and, on a more 
limited scale, in mice met with failure. The sera 
often seemed to reduce the natural resistance and 
to hasten death. It is our belief that the claims 
for the usefulness of antistreptococcus serum rest 
on impressions from results in clinical cases in man, 
and have in most cases no foundation whatsoever 
in experimental tests." The burden of proof 
apparently rests on the clinician. 
based on agglutination tests, each variety possess- 
ing its own specific reaction in this respect. 
Standardization.-The agglutination test is a 
useful index of the therapeutic potency of a serum; 
one that agglutinates in high dilutions the various 
strains used in its production, generally proves to 
be markedly curative. The test itself is only a 
measure of the degree of immunization, as the 
agglutinins themselves have probably nothing to 
do with the curative power of the serum; but in 
the absence of any direct method of standardiza- 
tion, the agglutination test is of considerable value. 
Dosage and Administration.-The conventional 
dose is 2 c.c. or about 40 minims, repeated every 
other day or at longer intervals, depending on the 
reaction obtained and the general condition of the 
patient. The serum is administered by the sub- 
cutaneous route; any convenient region such as the 
abdomen, or the loose areolar tissue in the scapular 
region or the arm may be selected. 
A local reaction, consisting of some swelling, 
redness, heat and soreness around the point of 
injection, occurs in most cases. 
Indications.-Antigonococcic serum has been 
extensively used by numerous investigators, and 
its indications are accordingly better established 
than is the case with most other therapeutic sera 
recently introduced into practice. There is 
fairly general agreement on two points: (1) That 
the serum is absolutely valueless in all acute 
gonorrheal infections, and (2) that it is of distinct 
value in chronic gonorrheal arthritis, which is 
accordingly the most positive indication for its 
employment. Distinct improvement with refief 
from pain is noted after the first injection, and not 
more than from six to ten doses are said to be 
required to effect a permanent cure. Doubtful 
results are also reported in subacute and chronic 
complications of gonorrhea affecting the genito- 
urinary tract, such as epididymitis and orchitis. 
On the other hand, gonorrheal iritis seems to be 
favorably influenced by the serum, while in con- 
junctivitis the results have been disappointing. 
It is stated that, in general, complications affect- 
ing the serous membranes respond to serum 
therapy, while gonorrheal infections and their 
complications involving the mucous membrane 
may be influenced best by the administration of 
bacterins. A positive contraindication is the 
presence of a generalized gonococcus infection. 
A serum obtained from horses immunized 
against a mixed culture of staphylococcus pyogenes 
aureus, albus and citreus. It is recommended in 
the treatment of various staphylococcus infections. 
The serum appears to have been but little used 
and has been superseded by the various staphyl- 
ococcus vaccines. 
Antistaphylococcus Serum. 
Antigonococcus Serum. 
A bacteriolytic polyvalent serum obtained from 
the blood of animals immunized against gonococci. 
Preparation.-The method employed is that 
devised by Rogers and Torrey. Cultures are 
grown for from eighteen to twenty-four hours on 
large slants (one-inch culture tubes) and, in order 
to obtain a luxuriant growth, the organisms are 
transplanted to a medium prepared as follows: 
Meat, peptone, 2 percent agar are prepared in the 
usual way and titrated to 1.5 percent acid to 
phenolphthalein. One part of rich sterile ascitic 
fluid is then added to two parts of this agar. The 
animals are inoculated with increasing quantities 
of virulent cultures grown in this way, after being 
emulsified in about 30 c.c. of physiologic saline 
solution and heated for one-half hour to 65° C. 
Rabbits were at first employed, but the serum was 
found to be toxic for some individuals and produced 
some alarming reactions. The same objections 
were found in a minor degree in goat serum, and 
the animal finally selected was the full grown, 
uncastrated ram, which is now exclusively used in 
the production of antigonococcus serum. The 
immunization requires ten weeks. 
The serum is polyvalent, cultures of the three 
principal groups of gonococci being used in its 
preparation. The selection of these groups is 
Antidiplococcus Serum.-See Cerebrospinal 
Meningitis. 
Antimeningitic Serum (Flexner). 
Experiments with the serum of various animals 
immunized against the pneumococcus date back to 
1891. One of the earliest was that prepared by 
Pane from the blood of asses, which was exten- 
sively used by Italian investigators and reported 
to have given good results. The sera now on the 
market are obtained from various animals, horses, 
sheep and cattle, by immunization with a number 
of different strains of pneumococci taken directly 
from individuals in various stages of pneumonia 
Antipneumococcus Serum. SERUM THERAPY 
SERUM THERAPY 
and presenting different degrees of severity of the 
infection. The serum is therefore polyvalent and 
some preparations are also composite, i. e., contain 
a certain percentage of diphtheria antitoxin, 
which is added by some manufactures in the belief 
that it enhances the bactericidal power of a serum 
by stimulating phagocytosis. 
Dosage and Administration.-The dose of Ameri- 
can preparations is given as 10 to 20 c.c., adminis- 
tered subcutaneously; on the other hand, very 
much larger quantities-from 200 to 400 c.c.-are 
recommended by some German investigators 
working with the Merck product. 
The serum produces a marked hyperleukocyto- 
sis, reduces the temperature, and has a direct 
influence on the blood-pressure, acting as a cardiac 
as well as a general tonic. It appears to be harm- 
less. The special indications for its use are severe 
infection with pneumococci circulating in the 
blood, cases with weakening circulation, exces- 
sively low blood-pressure and pulmonary edema, 
and the presence of ulcus cornese serpens. In the 
last named complication encouraging results are 
reported. 
among the control cases. As a prophylactic, on 
the other hand, the serum seems to be effective, 
but the immunity conferred is very brief, at most 
ten days in duration. 
Dosage and Administration.-The enormous 
quantity which appears to be necessary to produce 
any impression constitutes a serious practical 
objection to the use of the serum. With the Yer- 
sin serum the initial dose should be not less than 
100 c.c., and this dose is to be repeated two or even 
three times at intervals of eight hours. During 
succeeding days a daily injection of from 20 to 50 
c.c. is given, so that a single patient may receive 
as much as 590 c.c. The serum in order to be of 
any value must be administered before the third 
day of the disease, by the intravenous route. 
Under the name of "Pollantin" a serum ob- 
tained from animals immunized against the pollen 
of various plants and grasses, especially Indian 
corn, has been patented in Germany, Great 
Britain, the United States and other countries. 
The serum is prepared after the method of Dunbar, 
who isolated a toxalbumin from the pollen of a 
variety of grasses, especially wheat, rye, barley, 
Indian corn, golden rod and ragweed, and was 
able, by injecting a solution of this substance sub- 
cutaneously, to produce typical symptoms of hay 
fever in predisposed individuals. In the United 
States the early summer catarrh is caused chiefly 
by the pollen of rye and Indian corn; while the 
golden rod (Solid ago virgaurea) and ragweed 
(Ambrosia artemisicefolia') are held responsible for 
the autumnal variety so prevalent in this country. 
Dunbar believes that the pollen toxin is identical 
in the various plants, and utilized for the prepara- 
tion of his serum the pollen of Indian corn. 
Pollantin is marketed in liquid form and as a 
powder, and is intended for external use only, not 
for subcutaneous injection. Liquid pollantin 
contains 1/4 percent phenol, which, however, is 
not sufficient to inhibit bacterial growth, if the prep- 
aration is contaminated by contact with the nasal 
mucous membrane or the eye. 
Dosage and Administration.-In the manu- 
facturers' directions for using powdered pollantin 
the patient is instructed to fill about one-fourth of 
the scoop inserted into the glass tube, hold the 
scoop under one nostril, and sniff the powder 
while keeping the other nostril closed. The same 
dose is then applied to the other nostril. The 
powder may also be used in treating the eyes, a 
few grains being introduced into the conjunctival 
sac with a camel's hair brush. The dose of liquid 
pollantin is one drop in each eye, and four or five 
drops in each nostril. It is stated that the sub- 
stance is entirely harmless even in large doses. 
Pollantin should be used every morning and as 
often during the day as the symptoms seem to 
demand. 
Hay Fever Serum. Pollantin. 
Animal sera have been prepared by inoculations 
of both living bacilli (Shiga) and their soluble 
toxins. Reports as to the value of these prepara- 
tions are conflicting and they do not appear to 
have influenced the mortality of the disease in a 
very marked degree, while no influence on the 
morbidity is observed after the prophylactic use 
of antidysenteric serum. The dose is from 10 to 
40 c.c., injected subcutaneously. Pulverized cul- 
tures of killed dysentery bacilli have also been used 
in the same way. The remedy is advised both in 
true epidemic dysentry and in summer diarrhea 
of children. 
Antidysenteric Serum. 
Antityphoid Serum. 
The serum is obtained from horses injected with 
killed cultures of typhoid bacilli. As the tech- 
nical difficulties to be overcome in the preparation 
of typhoid serum are considerable, the remedy has 
been very little used and practically the only 
information available in regard to its efficiency is 
derived from Chantemesse, who treated a number 
of cases with a serum prepared after his own 
method with bacilli grown under anaerobic condi- 
tions upon a filtrate of an emulsion of splenic tis- 
sue digested with pepsin. The dose of Chantem- 
esse serum is from 10 to 12 c.c. for adults. In- 
terest in this serum has languished since the 
introduction of vaccine therapy. 
Antiplague Serum. 
Of the two preparations available, that prepared 
at the Pasteur Institute in Paris after the method 
of Yersin by immunizing horses with cultures of 
live, virulent bacilli, and the serum of Lustig and 
Galeotti, who employed nucleoproteins extracted 
from the bacilli, only the former is now used. 
The curative value of this serum is very small, as 
the mortality among patients treated with the 
serum is but little lower than that observed 
Normal Human Serum. 
The use of human blood serum is of quite recent 
development, and may be regarded as a simplifi- 
cation of direct transfusion, a very old therapeutic SERUM THERAPY 
SEWAGE DISPOSAL 
procedure recently revived and reintroduced into 
practice through the work of Crile and others. 
The many brilliant successes achieved by direct 
transfusion of whole blood from one human being 
to another sufficiently attest the merits of the pro- 
cedure; but, without entering into a discussion 
which would be out of place here, it must be 
pointed out that in not a few instances sudden 
death instead of the hoped for cure of the patient 
has resulted under circumstances which precluded 
the possibility of an ordinary surgical accident 
such as air embolism. Examination of such a 
patient's blood reveals hemolysis like that ob- 
served after the injection of a foreign serum in 
animal experiments, and the experience suggests 
that under certain conditions, as yet not under- 
stood, the transfusion of whole blood from one 
individual to another is an unsafe procedure. 
The injection of animal serum into human beings 
produces certain undesirable symptoms which may 
be briefly enumerated as: fever, urticaria both local 
and general, erythema and scarlatiniform erup- 
tions, cutaneous edema, pain and swelling of 
joints and, in rare cases, hemorrhage into hollow 
organs, edema of the glottis or even sudden death. 
(See Serum Intoxication and Anaphylaxis.) 
On the other hand, it is positively stated that the 
administration of human serum, whether in single 
or repeated doses, never produces serum disease or 
anaphylaxis in the human subject. The mode 
of action in the conditions in which human serum 
has been tried, which come under the two heads of 
hemophilia and bacterial infection, is still obscure; 
although it has been repeatedly demonstrated 
that normal blood serum possesses bactericidal 
properties. The results reported in the literature 
encourage a further trial of the procedure. These 
relate chiefly to hemophilia neonatorum or infection 
of the new-born, the identity of these two condi- 
tions being probable although not definitely 
established, puerperal infection and other bacter- 
emias. 
Dosage and Administration.-For infants the dose 
recommended is 10 c.c., injected subcutaneously, 
three times on the first day, and thereafter once 
a day as long as the symptoms appear to render 
it necessary. Four to five days usually suffice to 
effect a cure in cases of hemophilia neonatorum. 
The technic is thus described by Welch. "The 
apparatus consists of a flask with a rubber stopper 
through which are two perforations. Through 
one perforation is fitted a U-shaped glass tube, to 
the outer end of which is attached, by means of a 
piece of rubber tubing, a short aspirating needle 
having a No. 19 caliber. The needle is cotton- 
plugged into a small test-tube, in which it is 
sterilized. Through the other perforation is 
inserted a fusiform glass tube containing, cotton 
to prevent contaminating the contents of the flask. 
A small suction tube is placed on this latter for 
drawing the blood into the flask. The needle is 
inserted into a vein at the elbow and the desired 
amount of blood withdrawn. The blood is allowed 
to coagulate in a slanting position in the flask, and 
the serum is withdrawn as rapidly as it separates, 
and is then ready for use." 
Convalescent Sera. 
The use of convalescent sera in the treatment of 
acute infectious fevers is open to the theoretical 
objection that the subject from whom the serum is 
obtained has never, as in the case of animal immun- 
ization, gone through a course of artificial stimula- 
tion of his immunizing powers by the injection of 
gradually increasing doses of the bacterial toxin 
or bacterial cultures. In addition, the practical 
difficulty of obtaining such a serum in any con- 
siderable quantity will always prove a bar to its 
extended use. The serum is withdrawn from the 
convalescent soon after defervescence is definitely 
established, and injected subcutaneously in 10 c.c. 
doses. The method has been tried in pneumonia, 
measles, scarlet fever, diphtheria, typhoid fever 
and, quite recently, in pellagra. The number of 
patients treated after this method is as yet too 
small to permit the drawing of any conclusion with 
regard to its value. 
In addition to the therapeutic sera that have 
been discussed more or less fully in this article, 
there are a large number that have some claim on 
the attention of the student of bacteriology, but 
have hardly attained the practical importance 
which would justify their systematic treatment 
in an encyclopedic article. Among these may be 
briefly mentioned: antitubercle serum, which never 
passed beyond the experimental stage and has 
been superseded by tuberculin; various products 
obtained by inoculating animals with thyroid gland 
substance, of which the serum of Beebe and Rogers 
deserves special mention. The most recent studies 
with this serum have failed to realize the expecta- 
tions awakened by the early reports of its success- 
ful employment in exophthalmic goiter. The 
many attempts to discover a therapeutic serum 
for the cure of cancer have ended uniformly in 
failure, although the quest still continues. Sera 
have also been prepared for the cure of leprosy, 
yellow fever, and some experimental work has also 
been done in serum therapeusis of leukemia and 
other forms of blood dyscrasia. 
See Vaccine Therapy. 
SEWAGE DISPOSAL.-Sewage consists of 
human excreta, solid and liquid, together with 
house, factory and street waters and impurities. 
The mixture of feces and urine undergoes rapid 
putrefaction, resulting in gas formation (marsh- 
gas, ammonium sulphid, sulphuretted hydrogen, 
etc.). The urea of the urine is rapidly transformed 
into ammonium carbonate and then into ammonia. 
The bacteria present are chiefly the spirillum ru- 
gula, spirillum amyliferum; bacillus butyricus, 
bacillus putrificus coli, baeillus proteus sulphureus, 
bacillus proteus vulgaris, bacillus sulphureus, 
bacillus lactis aerogenes; and the micrococcus 
urese. Pathogenic microorganisms, such as the 
bacillus typhosus, cholerse, dysenterise (Shiga) and 
streptococci and staphylococci, may be present. 
No crude sewage should be discharged into a 
stream or river. Though in time such sewage 
would be purified if largely diluted, the water 
would be rendered unfit for drinking purposes. 
In towns on the sea coast sewage may be dis- SEWAGE DISPOSAL 
SEWAGE DISPOSAL 
charged directly into the sea, provided precautions 
are taken to prevent its being cast up by the tide or 
carried by currents along the coast. To obviate 
such dangers the outfall should be so placed that 
the currents may carry the sewage away from the 
town, the mouth of the outfall sewer being 
guarded by a valve and opening below the level of 
the water. In low-lying towns where any fall for 
sewage is impossible, one of the pneumatic 
methods of removing sewage is advisable. The 
Shone system acts by means of compressed air 
sent out from a central station. The sewage is 
received into ejectors into which, when full, the 
compressed air is admitted by a valve and forces 
out the sewage. In the Liernur and Berlier sys- 
tems the motive power is suction; a vacuum is pro- 
duced at the central station and the sewage is 
sucked through an air-tight system of sewers to 
the central reservoir. 
of 2000 to 5000 persons can be disposed of on one 
acre of land. In London before the sewage is dis- 
charged into the sea it is treated with lime and sul- 
phate of iron. Combinations of iron and alum, or 
alum and lime are also in use. 
Biologic Purification.-Depending on the prin- 
ciple that the decomposition and purification of 
sewage, which is chiefly organic matter, is essen- 
tially due to the action of microorganisms, newer 
methods than chemical treatment and land appli- 
cation have been adopted. These have the advan- 
tages of greater efficiency and marked reduction 
in the amount of sludge and in the expense and 
labor involved. 
In the changes occurring in sewage there are 
mainly two stages. The first is a process of diges- 
tion in which the anaerobes (microorganisms liv- 
ing without oxygen) play the chief role-the solid 
organic matter becomes liquefied, nonnitrogenous 
matter is reduced, albuminoid substances are 
peptonized; the second stage is one of oxidation, 
mineralization and nitrification, the ultimate 
result being mineral matters and gases-in this 
stage the work is done largely by the aerobes 
(oxygen-requiring microorganisms). The various 
types of installation in use at present are based 
upon the principle of separating these stages, with 
a view to placing the two main groups of micro- 
organisms in the most favorable conditions for 
work. The first stage is allowed to take place in a 
digestive tank under strictly anaerobic conditions, 
while the second stage is effected during the pas- 
sage through one or more aerating contact or filter- 
beds. Aerating filter-beds known as "streaming 
filters" are preferably constructed of coke, clinkers, 
flint, burnt ballast, coal, refuse pottery, and, less 
effectively, of sand or gravel. They have open 
outlets and afford the best means of securing effi- 
cient oxygenation of the effluent. 
Before entering the installation the sewage 
must always be passed through a "grit chamber" 
to be freed from all large mineral particles. When 
the crude sewage is highly offensive as a result of 
wastes from breweries, preliminary treatment in 
slate beds is advisable. 
The Scott-Moncrieff installation includes two or 
more "cultivation tanks" filled with large stones 
at the bottom and small above. The sewage 
passes to a false bottom on the floor of the tanks 
and escapes at the top. The effluent flows into a 
series of nitrification channels filled with large 
stones and exposed to the air. A modification of 
this system has a series of perforated trays con- 
taining filtering media over which the effluent 
slowly falls. 
The Sutton System advocated by Mr. Dibdin 
consists of straining, then downward filtration 
through coarse beds of burnt ballast 4 feet deep. 
The effluent passes into five filters 4 feet deep 
where it rests for 2 hours. These contact beds 
are emptied slowly and then allowed to rest 
several hours. By this intermittent application 
aeration is provided for. In a modification of this 
system the sewage rests 4 hours in the coarse beds 
and 2 hours in the fine beds (treatment in a series 
of which is more effective to that in merely one). 
Methods of Application to Land. 
(1) Broad Irrigation.-This consists in the dis- 
tribution of sewage over a large area of soil and is 
applicable to towns which can procure land of ade- 
quate size (one acre to every 100 to 200 people) 
and of suitable quality. Percolation of the sewage 
through the soil is provided for and stagnation is 
prevented by subsoil drains, unless the land is very 
porous. The sewage must be applied intermit- 
tently so as not to interfere with aeration of the 
soil. Large crops of Italian rye grass, roots (man- 
gold) and cabbage may be obtained from a sewage 
farm. 
(2) Filtration.-The increasing cost of land has 
led to the use of an equally effective but cheaper 
method-that of intermittent downward filtration 
on a small surface of especially porous land called 
a bacterial bed. The best soil is one rich in lime 
or alumina or hydrated iron oxid. The land is 
underdrained with porous tile drains and divided 
into sections, each of which receives screened 
sewage for 6 hours and rests the other 18 hours of 
each day. The process is that of oxidation and 
nitrification by microorganisms through the 
mechanical filter of the soil. This method is 
applicable to the sewage of considerably less than 
1000 persons per acre. Usually the land is divided 
into ridges, upon which vegetables are grown, and 
furrows, down which the sewage flows. 
If there is not sufficient land available to provide 
one acre for the sewage of each 1000 persons, pre- 
liminary treatment is necessary before the dis- 
posal on land: 
Sedimentation and Chemical Precipitation.-The 
sewage is treated with lime (about 12 grains to the 
gallon of sewage), or protosulphate of iron (2 to 5 
grains per gallon), or sulphate of aluminum (about 
5 grains per gallon) in settling tanks, having pref- 
erably a conical bottom, in order to remove sus- 
pended matters. The supernatant liquid is then 
applied to the land, or passed intermittently 
through special filters of sand, coke, coke-breeze, 
etc., or discharged into a large river or the sea. 
The sludge is generally partly rid of moisture by 
hydraulic filter presses and drying machines and 
used as manure. By this treatment the sewage SHINGLES 
SHOCK 
The Septic Tank Method.-The sewage enters a 
covered tank where it remains for a day under 
anaerobic conditions (rest and absence of air and 
light) and becomes liquefied. The effluent passes 
through the outlet and along a trough or aerator 
over the edge of which it falls in a thin film, 
combining with air to a certain degree, upon 
a series of coke-breeze filter-beds 4 1/2 feet 
deep. Each filter is filled in 6 hours, then after 6 
hours of rest it is emptied in a half hour and 
then left empty for aeration the remainder of the 
24 hours. Small septic tank disposal plants have 
been installed effectively for the sewage of large 
houses. 
Antiseptic Methods.-A purified effluent should 
be inodorous and not liable to undergo putrefac- 
tion. It is always potentially dangerous, however, 
for pathogenic organisms may still be present. 
Therefore prior to being thrown into a running 
stream, it is generally passed from the installation 
through a special sand filter or applied to land. 
Even then if discharged into waters where water- 
cress is grown or oysters or other shell fish are laid, 
there is danger of contamination. The question 
of sterilization of the effluent has given rise to 
considerable study. Antiseptics and deodorants 
are advised and may be used to advantage if they 
do not interfere with the work of the microorgan- 
isms. In the ABC process alum, blood, clay and 
charcoal are used. Manganate of sodium and sul- 
phuric acid are advocated. The Amines process 
consists of the addition of milk of lime and herring 
brine. Chlorin, either as chlorid of lime or gas, 
seems to be the most practical antiseptic. In 
the oxychlorid method, sea water or salt solu- 
tion is decomposed electrically. In one hour 
3 1/4 gallons are said to partially sterilize 1000 
gallons of effluent from a biologic instilla- 
tion. This treatment is claimed to render 
sewage effluent practically free from intestinal 
organisms. 
SHINGLES.-See Herpes Zoster. 
SHOCK.-Shock is a general prostration of the 
vital powers the result of injury or emotion. 
Local shock is numbness or anesthesia of a part 
which has been injured, and is seen most frequently 
in gunshot wounds. Collapse is the final stage of 
shock, or sudden profound shock coming on acutely. 
Exhaustion presents similar symptoms to shock, 
but comes on gradually, often following some 
exhaustive disease, such as carcinoma or tubercu- 
losis. 
The causes of shock are afferent impulses trans- 
mitted along the sensory or sympathetic nerves, or 
in emotional shock along the nerves of special 
sense, to the vital centers, especially the vaso- 
motor centers, which are thus weakened or ex- 
hausted (shock), or paralyzed (collapse); conse- 
quently there are marked lowering of the blood 
pressure, weakening of the propelling force of the 
heart and arteries, collection of the blood in the 
veins, especially the large abdominal veins, and 
anemia of the brain, lungs, and superficial parts of 
the body. 
The symptoms vary in intensity according to the 
severity and situation of the injury, the psychical 
condition, age, sex (women are more susceptible) 
and previous general condition of the patient, and 
according to various other factors, such as hemor- 
rhage, exposure to cold, etc. In torpid or apa- 
thetic shock there are marked pallor of the skin and 
mucous membranes, cold clammy perspiration, 
elongated, pinched, expressionless face, half open 
mouth, half closed shrunken eyes, lusterless cornea, 
dilated pupils reacting slowly to light, weak and 
rapid pulse, accelerated (occasionally slow) shallow 
and irregular respirations, mental apathy, subnor- 
mal temperature, impaired sensation of the skin, 
retention of urine, and sometimes incontinence of 
feces. If the shock is due to or aggravated by 
hemorrhage, there may be great restlessness and 
other symptoms commonly associated with the 
loss of a large quantity of blood. During the pe- 
riod of reaction there may be vomiting, great rest- 
lessness or excitement, and even delirium (ere- 
thistic shock), particularly in conditions like ex- 
tensive burns, in which a toxic factor is added. 
Shock which does not appear for several hours 
{delayed or secondary shock) is most frequently 
seen after railway accidents, alcoholic intoxi- 
cation, and severe emotional storms. After 
operation delayed shock is almost always due to 
hemorrhage 
The symptoms of hemorrhage are practically 
identical with those of shock, in fact the condition 
after hemorrhage is shock due to loss of blood. 
In concealed hemorrhage one does not see the blood, 
and the question arises whether the symptoms are 
due to shock alone, or to shock the result of hemor- 
rhage. In hemorrhage there is apt to be greater 
restlessness, and instead of torpidity, great anxiety 
and foreboding on the part of the patient who 
complains of loss of sight, asks for water, and gasps 
for air; the skin and mucous membranes are ex- 
cessively pale, and the pulse, although very" fre- 
quent, is likely to be larger and more compressible 
than that of shock. The hemolgobin is greatly 
lessened in hemorrhage (but not for a number of 
hours) and unreduced in shock. The most reliable 
signs are those of fluid in a cavity, i.e., in the chest 
or abdomen. In case of doubt, especially after an 
abdominal operation or injury, an exploratory in- 
cision should be made. 
The prophylaxis of shock is possible in surgical 
operation. In addition to reassuring a nervous 
patient, the physical condition may be improved. 
With the patient in poor condition shock may be 
anticipated by the application of warm water bags, 
the hypodermatic injection of strychnin and atro- 
pin, the careful covering of the patient during 
operation, the avoidance of excessive purgation 
and prolonged abstention from food before opera- 
tion, and by celerity, gentleness, and careful 
hemostasis during the operation. The part to be 
operated upon may be placed in a slightly higher 
position than the rest of the body in order to lessen 
hemorrhage. The use of a local anesthetic for the 
prevention of shock in extensive operations is of 
doubtful value, as the fright of the patient, and the 
increased time necessary for the performance of the 
operation, owing to the struggles of the patient 
more than counter-balance any depressing influ- SHOULDER, AMPUTATION 
SHOULDER, DISLOCATION 
ence of a general anesthetic. In head operations 
Crile applies a temporary clamp to the carotid, 
places the patient in a pneumatic rubber suit, and 
elevates the upper part of the body 45°. In opera- 
tions on the dangerous area of the larynx, in which 
sudden collapse may follow from reflex inhibition 
of the heart and respiration as the result of stimu- 
lation of the superior laryngeal nerve, he advises a 
preliminary dose of atropin, or the application of 
cocain to the nerve endings in the pharynx; in the 
extremities he blocks the nerve trunks by injecting 
into them cocain. 
The treatment of shock consists in raising the 
feet and lowering the head; the application of care- 
fully protected warm-water bags; the hypoder- 
matic injection of ether 1 dram, brandy 1 dram, 
strychnin grain 1/20, digitalin grain 1/10, atropin 
grain 1/100, ergotin 10 minims, or camphorated 
oil 1 dram, inhalations of ammonia, alcohol, or 
oxygen; the rectal injection (enteroclysis) of hot 
coffee 1 pint, whisky 1 ounce, or turpentine 1/2 
ounce with salt solution; and autotransfusion, 
hypodermoclysis, or intravenous infusion of adren- 
alin chlorid in the strength of from 1 to 50,000 to 
1 to 100,000 in salt solution. As a rule from 10 
minims to a half dram of a 1 to 1000 solution is 
dropped into two quarts of salt solution, which is 
slowly injected into a vein. Autotransfusion is the 
application of bandages to the extremities for the 
purpose of driving the blood to the vital centers. 
Crile uses the same principle by the application of a 
rubber suit, which is blown up with a bicycle pump. 
Mustard plasters may be put over the heart and on 
the extremities, and stretching the sphincter ani 
has been recommended. If the respirations fail 
despite stimulation, artificial respiration should be 
performed. Transfusion of blood and massage of 
the heart have been employed in a few cases. 
Operations are not, as a rule, performed during the 
presence of shock, unless it is known that the shock 
is being increased by the condition for which the 
operation would be performed, e. g., hemorrhage, 
perforation of a hollow viscus, and some cases of 
crushed extremities (Stewart). See Collapse; 
and Infusion of Saline Solutions. 
SHOULDER, AMPUTATION. The Flap Method. 
-The patient is placed on a firm table, with the 
arm well raised and projecting beyond its edge; 
the subclavian artery being compressed, the opera- 
tor enters a long, narrow, straight bistoury at the 
anterior margin of the deltoid muscle, if it is the 
right arm, an inch below the acromion. From this 
point he thrusts it through the muscle, across 
the outside of the joint, and brings it out at 
the posterior margin of the axilla. If the left 
arm is operated on, the knife must be entered at 
the posterior margin of the axilla and brought out 
at the anterior margin of the deltoid. Then, by 
cutting downward and outward the external flap is 
made. The arm is then brought down to the side 
and forcibly adducted; the origins of the biceps 
and triceps and the insertions of the infraspinatus 
and supraspinatus are cut through and the joint 
laid open. Finally, the blade of the knife, being 
passed through the joint and placed on the inner 
side of the head of the bone, is made to cut an 
inner flap of the same shape, but rather shorter 
than the outer one. 
Oval Method.-In order to control hemorrhage, 
pins similar to those already described for amputa- 
tion of the Hip-joint (q. v.) are now employed: 
one to be passed through the pectoralis major 
muscle and brought out in front of the acromion 
process; the other passed through the latissimus 
dorsi muscle and brought out back of the acromion. 
The points are to be protected by cork. The 
rubber band is to be put on above the line of opera- 
tion, and is to be removed as soon as the limb 
is amputated and the vessels secured. Make a 
straight incision immediately beneath the acromion 
process, and a little toward the anterior border 
of the axilla, with a moderate-sized amputating 
knife, which should reach down to the bone, and 
should be between 2 1/2 and 3 inches in length; 
from the lower end of this incision two others are 
prolonged, the first passing in a curved direction 
downward and backward, and the second forward 
toward the folds of the axilla, the blood-vessels 
and the inner or axillary aspect of the arm re- 
maining untouched. The flaps are then dissected 
back, including the muscles and exposing the joint. 
The head of the bone is then disarticulated by 
cutting upon the tuberosities, the arm being 
rotated inward and outward. The arm is then 
adducted, throwing the head of the humerus 
outward, and the knife is passed to the inner 
side and carried downward close to the bone, an 
assistant at the same time compressing the 
artery. Then the tissues between the axillary 
folds are divided by an oblique cut from with- 
in outward so as to form part of the internal 
incision. 
The axillary artery and branches of the anterior 
and posterior circumflex and of the suprascapular 
arteries are to be tied. 
SHOULDER, DISLOCATION.-Shoulder-j oint 
dislocations are quite frequent, and are usually 
readily diagnosed, but sometimes evade recog- 
nition. 
Forward luxation of the humerus is the most 
frequent of the shoulder dislocations, and, ac- 
cording to the degree of displacement, is de- 
scribed as preglenoid, subcoracoid, and subclav- 
ian; the degree termed subcoracoid is most 
common. Sometimes the dislocation is some- 
what forward and downward (infraglenoid) pri- 
marily, and becomes subcoracoid by a secondary 
displacement. 
Forward displacement may result from direct 
violence, as a sharp blow on the shoulder from the 
side and behind; but generally results from in- 
direct violence, as pushing the elevated arm power- 
fully backward. Occasionally, muscular action 
(hurling a stone) may produce it. 
The symptoms of subcoracoid dislocation are 
characteristic: the head of the bone is absent from 
the glenoid fossa and presents beneath the cora- 
coid process; the rounded outline of the shoulder 
has disappeared, the acromion hanging over and 
forming an angular projection; the long axis of the 
arm passes under the coracoid process instead of 
beneath the acromion; as a result, the arm is held SHOULDER, DISLOCATION 
SHOULDER, DISLOCATION 
abducted; the elbow can be pressed against the 
body, but on being released springs back immedi- 
ately to its abducted position (elastic fixation). 
The outer contour of the arm is no longer al- 
most straight, but forms an angle opening out- 
ward, with its apex at the humeral insertion of 
the deltoid. Voluntary movements are much 
restricted and passive movements are limited 
and painful. 
Injuries to the blood-vessels are rare; the nerves 
are put on the stretch, and are sometimes injured, 
especially the circumflex nerve, resulting in serious 
injury to, and sometimes atrophy of, the deltoid 
muscle. 
In making the diagnosis the following condi- 
tions must be differentiated: 
Paralysis of the deltoid, with descent of the 
arm; fracture of the acromion; upward dislocation 
of the acromial end of the clavicle; fracture of the 
neck of the scapula; and fracture of the neck of 
the humerus. 
Treatment.-Kocher's method is always to be 
attempted: first, without an anesthetic; and, if 
unsuccessful, then with an anesthetic. It is 
uniformly successful except in cases of very exten- 
sive laceration of the capsule. This procedure is as 
follows: The elbow, fixed at a right angle, is 
pressed closely against the side; the forearm is next 
turned as far as possible away from the trunk, 
causing external rotation of the bone-head; the 
elbow is next carried across the chest, forward and 
upward, the external rotation of the bone-head 
being meanwhile maintained; and, finally, the 
hand is placed on the opposite shoulder, pro- 
ducing inward rotation. It may be useful to 
have an assistant press the head outward with the 
fingers during the latter manipulation. The 
classic method of Sir Astley Cooper is also of ser- 
vice in some cases (traction upon the arm in the 
longitudinal direction, with simultanous pressure 
of the foot-unshod-in the axilla, making direct 
pressure on the head). 
After reduction, the arm should be fixed 
by slings or bandages (Velpeau's) so that the 
head of the injured side rests on the opposite 
shoulder. 
Upward (supracoracoid) dislocation is extremely 
rare, and is always associated with fracture of the 
coracoid process. 
Downward (subglenoid or axillary) dislocation is 
usually the result of a fall upon the hand or elbow 
with the arm raised. The appearance is character- 
istic: the bone-head can be felt in the axilla, and 
when the arm is raised at right angles, the change 
in axial line, together with the empty socket and 
the overhanging and prominent acromion, make 
the condition evident. 
A subvariety of this injury is the luxatio erecta, 
in which the arm is directed upward, with the 
forearm held behind the head to avoid pain. 
Reduction is easily effected by traction on the 
arm, together with direct outward pressure 
against the bone-head. 
The following useful table (Pick) will aid in 
diagnosing the various forms of dislocation of the 
shoulder: 
Direction of' 
the Axis of 
the Limb. 
Alteration 
IN THE 
Length of 
the Limb. 
Presence of 
the Head of 
the Bone in 
New Situa- 
tion. 
Subcoracoid. 
The elbow is 
carried back- 
ward and 
slightly away 
from the side. 
Very slight 
lengthening. 
The head of the 
bone cannot 
easily be felt; 
if it can, it is 
found at the 
upper and in- 
ner part of the 
axilla. 
Subglenoid... 
The elbow is 
carried away 
from the 
trunk and 
slightly back- 
ward. 
Very consider- 
able length- 
ening. 
The head of the 
bone can easily 
be felt in the 
axilla. 
Subspinous.. 
The elbow is 
raised from 
the side and 
carried f o r- 
ward. 
Lengthening 
intermediate 
in degree be- 
tween the sub- 
glenoid and 
the subcora- 
coid. 
The head of the 
bone can be 
felt and be 
grasped be- 
neath the spine 
of the scapula. 
Subclavicu- 
lar. 
The elbow is 
carried out- 
ward and 
backward. 
Shortening ... 
The head of the 
bone can read- 
ily be seen and 
be felt beneath 
the clavicle. 
Backward (retroglenoid, subacromial, sub- 
spinous) dislocation is very rare, and is usually the 
result of direct force. The prominence of the 
bone-head in its new position and the projection of 
the coracoid process make the diagnosis easy. 
Traction, together with adduction and direct pres- 
sure, effects reduction. 
Irreducible Dislocations.-When dislocation is 
accompanied by fracture of the humeral shaft or 
fracture below the anatomic neck-as by the sepa- 
ration of the tuberosities, or by a dislocation of the 
long head of the biceps, with its twining about the 
humeral neck-primary reduction may be accom- 
panied by insurmountable difficulties. Under 
these circumstances there can hardly be a question 
about the propriety of immediate operation. The 
very brilliant result obtained by McBurney and 
others by the use of a bone hook inserted into the 
upper fragment through an open incision, thereby 
making reduction of the dislocated head feasible, 
will in the future justify like procedures in all 
similar cases. In unreduced dislocations of older 
date the question of operative interference must 
be entirely determined by the degree of disability 
entailed. When this is slight, and the patient is 
able to gain a livelihood, and when pressure-symp- 
toms produced by the dislocated head are absent, 
the advisability of operative interference must be 
questioned, particularly if the dislocation is one of 
more than two or three months standing. Posi- 
tive indications for operative interference are pres- 
sure upon the vascular or nerve-trunks with which 
the head of the humerus has formed new relations. 
The present status of the question of operative 
interference in shoulder luxations may be sum- 
marized as follows (Ransohoff): 
1. Immediate operative interference is indicated SHOULDER, EXCISION 
when the ordinary methods by manipulation 
under anesthesia have failed. 
2. In irreducible dislocations operations should 
not be delayed until irremediable changes have 
taken place in the capsule and about the humeral 
head. In comparatively recent cases arthrotomy 
offers the best results. 
3. In long standing cases the conditions found 
must determine the choice between arthrotomy 
and resection. 
4. In unrecognized dislocations of long standing 
-one year or over-only grave compression symp- 
SIDEROSIS 
exposed at the bottom. This should be preserved, 
if possible; sometimes it is in a pulpy condition, 
or has already been eroded, and occasionally it is 
fixed firmly to the bone in its groove, and the up- 
per end of it is lost. The capsule is then freely 
opened and the condition of the parts examined 
before determining how much it is necessary to 
take away. 
So far as the subsequent utility of the limb is 
concerned, there is no doubt that the more of the 
bone that is left, the better. Partial resections 
(in which some of the head is left, the rest being 
gouged away) give better results than when the 
anatomic neck is divided; and this is to be preferred 
to the surgical neck. The entire diseased process 
must be removed (in cases of tumors springing from 
the head of the bone, one-third, and in some cases 
even more, of the shaft has been excised, preserv- 
ing the elbow and the hand); but consistently 
with this, as little as possible of the healthy bone. 
The question of subperiosteal excision is still 
open, but there is ground for believing that when 
it is practicable, the results are superior to the 
other method. If the surgical neck requires 
division, the arm must be strongly rotated out- 
ward by the assistant as soon as the capsule is 
opened, in order that the tendon of the sub- 
scapularis may be cut; and then inward for the 
short external rotators. As soon as this is done 
the head of the bone rises well up into the wound, 
and may be either sawed off with a narrow- 
bladed saw in situ, the soft parts being protected 
and held aside by retractors, or thrust bodily 
out. The glenoid fossa very rarely requires more 
than the application of a gouge. 
A counteropening at the back of the joint is 
usually advisable for drainage. The wound is 
thoroughly cleansed; the margins drawn together 
with sutures; a large tube placed across it; and the 
cavity of the axilla,, the space behind the shoulder, 
and the outer side and front of the arm thoroughly 
packed with wood-wool. Stromeyer's elbow 
cushion should be used as long as the patient is in 
bed, and passive motion commenced as soon as 
the condition of the wound allows it, the fingers 
and wrist being exercised from the first (Moullin). 
SIALAGOGS (Ptyalagogs).-Agents which in- 
crease the secretion and flow of saliva and buccal 
mucus, either by reflex action from local irritation 
produced when anything is taken into the mouth, 
or by stimulating the glands during their elimina- 
tion. The principal sialagogs are divided into 
two groups: (1) topical sialagogs acting by reflex 
stimulation; the chief of which are: Acids and 
alkalies, ether, chloroform, mustard, ginger, pyre- 
thrum, mezereon, tobacco, cubebs, capsicum, rhu- 
barb, horse-radish, (2) general sialagogs, acting 
through their systemic influence on the glands 
or their secretory nerves; the chief of which are: 
Pilocarpus (jaborandi), muscarin, physostigma, 
mercurials, iodin compounds, antimonials, to- 
bacco, ipecacuanha. 
Agents which diminish salivary secretion are 
called Antisialagogs {q. v.). 
SIDEROSIS.-Pigmentation of the lung tissue 
due to inhalation of metallic particles. 
Diagram of most common Varieties of Dislocation of 
the Shoulder.-{Thomson and Miles' Manual of Surgery). 
toms must be recognized as indications for inter- 
ference. 
5. Special attention must be given to the pre- 
vention of sepsis, since, in a very large proportion 
of cases recorded, sepsis has been either the cause 
of death, or, by the destruction of the humeral head 
or obliteration of the joint cavity, has frustrated 
the very object of the operation. 
SHOULDER, EXCISION.-This may be required 
for injury or disease. Ankylosis is compensated 
for so thoroughly by the mobility of the scapula 
that it is a question whether operation is advisable. 
It has also been performed for unreduced disloca- 
tion in which the head of the bone was resting 
upon the bracial plexus, and for tumors in con- 
nection with the upper extremity of the humerus. 
The usual incision is vertical, between 3 and 4 
inches in length, beginning just outside the coracoid 
process, on a level with it, and carried through the 
skin, fascia, and deltoid, down to the bone. If 
the arm is rotated outward and the soft part 
drawn to the sides, the tendon of the biceps is SIDONAL 
SIDONAL.-Quinate of piperazin. It is used 
in uricacidemia, gout, rheumatism in doses of 
5 to 20 grains in the form of powder or solution, 
75 grains being given in 24 hours. 
SIGHT.-See Vision. 
SILK AND SILKWORM-GUT.-See Ligature. 
SILVER (Argentum).-Ag = 108; quantivalence 
1. A malleable and ductile metal of brilliant 
white luster. It tarnishes only in the presence of 
free sulphur, sulphur gases, and phosphorus. 
It is an excellent substance for vessels used in 
pharmacy and for sutures used in surgery. 
Therapeutics.-Internally, the silver salts are 
used in dyspepsia with vomiting of yeasty fluid; 
chronic gastritis and gastric ulcer; dysentery of 
chronic type, especially if rectal ulcer (the nitrate 
internally and by enema); the diarrhea of phthisis 
and typhoid fever (nitrate with opium); chronic 
spinal inflammations causing locomotor ataxia 
or paraplegia; and epilepsy (in the latter affection 
the nitrate has occasionally given good results). 
The oxid has been used internally for gastric 
neuralgia, irritative dyspepsia, pyrosis, gastric 
and pulmonary hemorrhages, and menorrhagia. 
Used locally, the nitrate of silver is caustic, 
excitant, astrigent, and hemostatic. Strengths 
of nitrate of silver sufficient to prove astringent 
are also apt to be irritative. Thus, when used on 
mucous surfaces, the agent is liable to excite the 
mucous glands, if not to increase the inflammation. 
Under other conditions the irritating quality of 
the drug acts to advantage, and it is often selected 
when an excitant, and at the same time astringent, 
effect is desired. Nitrate of silver is a weak 
caustic on the most delicate tissues, but is a futile 
one on tough, resistant tissues. It is an astringent 
and hemostatic through the direct constricting 
effect it exerts on the caliber of the smaller 
vessels, and in the pressure exerted on them by 
the hygroscopic albuminate created by the 
salt. 
In gastric catarrh: 
3- Silver nitrate, gr. v 
Extract of hyoscyamus, gr. x. 
Mix and make into 20 pills. Take one 3 times 
daily, a half-hour before meals. 
In typhoid fever: 
ordinative power, convulsions, and, finally, death 
by paralysis of respiration. Large doses produce 
violent gastroenteritis; also ulcer of the stomach 
from thrombosis of its veins and destruction of 
the gastrointestinal mucous membrane. 
Common salt freely used is the antidote, precip- 
itating the silver as the insoluble chlorid and act- 
ing as an emetic. The nitrate is exceedingly 
sensitive to organic material and light, which de- 
compose it readily. Incompatibles are all the 
soluble chlorids (hence it should be used in distilled 
water), most of the mineral acids and their salts, 
alkalies and their carbonates, lime-water, and 
astringent infusions. A course of silver medica- 
tion should be regulated by suspending the remedy 
after 5 or 6 weeks' use, and then promoting elim- 
ination by purgatives, diuretics, and baths. To 
prevent the general discoloration, potassium iodid 
should be given conjointly with the silver, and 
baths of sodium thiosulphate should be used 
frequently. 
Preparations.-There are three official salts, the 
nitrate, cyanid, and oxid. 
Argenti Nitras, AgNO3, occurs in colorless 
rhombic crystals, of bitter caustic taste and neu- 
tral reaction, soluble in 0.6 of water and in 26 of 
alcohol. Is best given in pill with kaolin, or in 
distilled water; never with tannin or a vegetable 
extract, lest an explosive compound result. Dose, 
1/6 to 1/2 grain; if watched, up to 1 grain may be 
given. When melted with 4 percent of hydro- 
chloric acid, it makes: A. Nitras Fusus, Lunar 
Caustic, for local use as a mild caustic and astrin- 
gent. A. Nitras Mitigatus is the same salt melted 
with twice its weight of potassium nitrate. It is 
used locally by ophthalmologists. A. Cyanidum, 
AgCN, has no medicinal use except for the ex- 
temporaneous preparation of hydrocyanic acid. A. 
Oxidum, Ag2O, a brownish-black powder, nearly 
insoluble in water and insoluble in alcohol. It is 
liable to decompose with violence when mixed or 
triturated with readily oxidizable or combustible 
substances as creosote, phenol, potassium perman- 
ganate and many others. It should not be brought 
into contact with ammonia. Dose, 1/2 to 2 grains 
in pill with kaolin. It is not a dangerous internal 
remedy. A. Citras, called also antiseptic Credd. 
See Itrol. A. Lactas, see Actol. See also Ar- 
gonin; Argyrol. 
SINAPIS.-See Mustard. 
SINAPISM.-See Poultice. 
SINGULTUS.-See Hiccup. 
SINUSES, ACCESSORY, DISEASES.-See Nose 
(Accessory Sinuses). 
SIX HUNDRED AND SIX.-See Syphilis. 
SKIAGRAPHY.-See Roentgen Rays. 
SKIASCOPY.-See Retinoscopy. 
SKIN-DISEASES, DIAGNOSIS.-Skill in the 
diagnosis of diseases of the skin requires not only 
a sound knowledge of the principles of medicine, 
but also an acquaintance with the pathology of 
cutaneous disorders; it is, besides, necessary to be 
familiar with the physiology and minute anatomy 
of the integument. 
It should be remembered that the same patho- 
logic conditions that are found acting elsewhere on 
SKIN-DISEASES, DIAGNOSIS 
1$. Silver nitrate, gr. vj 
Extract of opium, 
Extract of belladonna, 
each, gr. ij. 
Divide into 24 pills. One pill 3 times daily 
after taking food. 
Poisoning.-Given internally in small doses, 
silver salts increase secretion, stimulate the heart, 
promote nutrition, and act as a nerve tonic. Their 
continued use produces symptoms which are col- 
lectively termed argyria, and are as follows: Gas- 
trointestinal catarrh; tissue waste; uremia; albu- 
minuria; fatty degeneration of the heart, liver, and 
kidneys; hemorrhages; fluidity of the blood; a slate- 
colored line along the margin of the gums and a 
similar discoloration of the skin and mucous mem- 
branes, with centric impairment of the nervous 
system, producing extensive paralysis, loss of co- SKIN-DISEASES; DIAGNOSIS 
SKIN-DISEASES, DIAGNOSIS 
the economy are also present in the skin; and that, 
therefore, this organ is equally subject to such proc- 
esses as anemia and hyperemia, atrophy and hyper- 
trophy, inflammation, new growth, and infection 
from animal and vegetable parasites; but it should 
also be recalled that while many, perhaps the major- 
ity, of these alterations are local in character, some 
of them are the result of general states, although 
not to the extent, and not even in the manner, 
that our humoralistic predecessors imagined. 
With so much premised, it is but just to say that 
the difficulties of diagnosis in this branch of medi- 
cine have been considerably exaggerated-the re- 
sult in part, perhaps, of undue refinement in classi- 
fication and unnecessary pedantry in nomenclature. 
Experience has shown that many of these difficul- 
ties may be minimized, and the way made 
smoother, if some systematic method of examina- 
tion is followed. 
However, before entering into details, attention 
may be directed to the importance of endeavoring, 
first, to establish the diagnosis from the objective 
symptoms present in a given case. Until he has 
made the diagnosis as far as it is possible to make 
it by these visible and tangible signs of disease, the 
physican should keep himself as free as may be 
from preconceptions arising from the patient's 
statements or his own interpretations of past events. 
For example, it is seen often enough that, when 
the examiner presumes, rightly or wrongly, that a 
patient has had syphilis, his whole investigation 
is tinctured by that presumption. This mental 
attitude is all the more pronounced in those with 
but scant experience in dermatology. Of course, 
it is not always possible to draw a sharp line in 
these matters, and the scheme to be presented is 
to be regarded merely as suggestive. 
Light.-In examining the skin for evidences of 
disease, artificial light should be avoided, and the 
first examination, at any rate, should be made in 
the daytime. Only in this way can slight differ- 
ences in shades of color be detected-a matter at 
times of no slight importance: as, for example, in 
syphilis, tinea versicolor, and certain pigment 
anomalies. 
Temperature of the Room.-If a patient is un- 
dressed in a cold apartment, upon exposure the 
skin will become mottled from congestion, and 
will take on an appearance simulating closely 
certain erythematous disorders, especially the early 
erythematous syphilid, or other like conditions. 
Consequently, an examination should always be 
conducted in a pleasantly warmed room. Having 
thus arranged the surroundings of the patient, 
attention may next be turned to the patient himself. 
General Inspection.-The physician should never 
rest contented with the patient's statement in 
regard to the character and location of an eruption: 
as, for instance, that a certain patch on the ab- 
domen is exactly like one on the face, etc. On the 
contrary, the examination should be thorough, and 
as much of the surface of the body inspected as 
possible; and even in the case of women, this may 
readily be effected by examining different portions 
of the skin successively. As a matter of course, 
this practice may be neglected in conditions obvi- 
ously localized; but in generalized eruptions or in 
doubtful cases it is an absolute necessity to satis- 
factory diagnosis. By way of illustration, the 
fact may be cited that the nature of an ill-defined 
lesion of psoriasis on the face may be fully estab- 
lished by more characteristic types of the same 
disease if the elbows and knees are inspected. 
Again, the differential diagnosis between eczema 
and scabies may be made, both affections having 
certain features in common, if, upon a general 
survey of the body surface, the eruption in the 
latter disorder is found to occupy the classic sites 
of scabies: viz., between the fingers, at the wrists, 
the axilte, the pubic region, especially the penis 
in the male, under the breasts in women, the but- 
tocks, the inner sides of the thighs, and, in fact, 
wherever there are heat and moisture. 
Extent of Surface Involved.-In making the gen- 
eral inspection just recommended, attention must 
also be paid to the amount of surface involved and 
to the localities occupied by the eruption. In 
addition to the illustration just given, it should be 
recalled that the exanthems usually cover the 
whole body; that the early syphilids are widely 
distributed; that acne is seated upon the face and 
shoulders; that psoriasis is likely to be sym- 
metrically disposed; and that tinea versicolor is 
found on the trunk, xanthoma on the lids, lupus 
and epithelioma generally on the face, and lupus 
erythematosus on the nose and cheeks. 
Arrangement of Lesions.-It is important to 
know whether the lesions occupy one or both sides 
of the body, and whether they possess any special 
arrangement. For example, in zoster the eruption 
is unilateral and the eruptive elements follow the 
course of cutaneous nerves, displaying clusters of 
vesicles on a red base. In ringworm the lesions 
affect a ringed arrangement, and extend at the 
periphery while clearing in the center. This dis- 
position is also to be noted in psoriasis and in some 
syphilids; herpes iris is annular. Moreover, the 
eruption in syphilis is often grouped-a feature 
also to be observed in dermatitis herpetiformis; 
but the first-mentioned affection presents no 
marked subjective symptoms, whereas in the latter 
there are intolerable itching and burning. 
Color.-The color of an eruption is often at least 
an auxiliary aid to diagnosis. The brownish-red 
or ham color of some syphilids differs from the 
underlying brighter red of psoriasis, and it also 
may be said that the thick greenish crusts of 
syphilis are fairly characteristic. The favus cups 
are sulphur-yellow; the patches of tinea versicolor 
are of a fawn tint; keloidal tumors are pinkish; 
and the new growths of xanthoma are buff-colored. 
In the same way the shade of color presented by an 
inflammation of the skin will measurably indicate 
its acute or chronic character. 
Touch.-The affected skin should also be pinch- 
ed up between the fingers, in order to get as accu- 
rate an idea as possible of the amount of infiltration 
present, the special tissues involved, the tempera- 
ture, the presence or absence of fluctuation, etc. 
An account of the symptoms revealed by the 
educated touch will often determine whether a 
disease is superficial or deep-seated, and thus SKIN-DISEASES, DIAGNOSIS 
eliminate whole groups of disorders from the field 
of discussion. 
Odor.-The odors arising from certain diseases 
of the skin are at times helps to their diagnosis. 
Favus has a peculiar mouse-nest smell; syphilitic 
ulceration emits a nauseating stench that is 
suggestive; while the smell of gangrene is well 
recognized. 
Acute or Chronic.-The objective aspect of the 
disease is indicated by these terms rather than the 
time occupied in its development, the latter point 
receiving notice more particularly when the pre- 
vious history of the case is under inquiry. For 
example, an eczema may have an acute appearance 
although a long time in existence, while a syphilid 
may be of recent origin yet lack all evidence of 
acuteness. Any changes that may have occurred, 
such as crusting, scarring, and the like, should be 
carefully noted, and the extending or outer margin 
of a patch should be especially observed, as often in 
this way we may detect the primary lesions (e. g., 
in lupus) of an eruption that has been disguised by 
complications or treatment. 
Individual Lesions.-It so happens that diseases 
of the skin, whatevei may be their cause or nature, 
impress themselves upon the integument by cer- 
tain elementary forms called primary lesions, 
which have been justly termed the alphabet of 
dermatology; and there are also to be observed 
certain other manifestations that are partly the 
sequels of the initial processes or are the effect upon 
them of traumatism-these are termed secondary 
lesions. 
The primary lesions consist of macules, papules, 
vesicles, .blebs, pustules, tubercles, wheals, and 
tumors. 
Macules are discolored patches of skin, of variable 
shape and size, without elevation or depression. 
Papules are circumscribed solid elevations of the 
skin, varying in size from that of a pinhead to that 
of a pea. 
Vesicles are pinhead-sized to pea-sized circum- 
scribed elevations of the epidermis, containing 
clear or opaque fluid. 
Blebs are round or irregularly shaped pea-sized 
to egg-sized elevations of the epidermis, containing 
clear or opaque fluid. 
Pustules are circumscribed, flat, or acuminate 
elevations of the epidermis, containing pus. 
Wheals are edematous, circumscribed, irregular, 
pinkish elevations of the skin, transitory in 
character. 
Tubercles are circumscribed, solid, deep-seated 
elevations of the skin attaining or exceeding the 
size of a pea. 
Tumors are variously sized and shaped promi- 
nences, having their seat in the corium or sub- 
cutaneous tissue. 
The secondary lesions comprise scales, crusts, 
excoriations, fissures, ulcers, scars, and stains. 
Scales are dry epidermal exfoliations shed from 
the surface of the skin. 
Crusts are brownish or yellowish masses of dried 
exudation. 
Excoriations are epidermal denudations, usually 
the result of local traumatism. 
SKIN-DISEASES, DIAGNOSIS 
Fissures are linear cracks or wounds in the 
epidermis or corium due to disease or inj ury. 
Ulcers are round or irregular losses of tissue in- 
volving the skin and subcutaneous tissue. 
Scars are connective-tissue new formations 
occupying the region of former losses of tissue. 
Stains are discolorations of the skin left after the 
disappearance of cutaneous lesions. 
While it is absolutely necessary for one desiring 
a knowledge of dermatology to know thoroughly 
these pathologic processes, it is not claimed that 
the recognition of a primary or secondary lesion 
will immediately give a clue to the diagnosis; for 
it is well known that these lesions are due to the 
most varied morbid states, and that the same kinds 
of lesions will often be found in very dissimilar 
diseases. If, however, the type of the lesion has 
been determined, at least the field of investigation 
has been considerably narrowed. For instance, it 
is of decided advantage to be aware that in herpes 
zoster there are vesicles and not tubercles; that in a 
disorder presenting macules we have not to deal 
with pemphigus or acne or urticaria, for these 
affections are characterized by an entirely different 
order of lesions. The same reasoning holds good, 
in a measure, for secondary lesions, such as crusts, 
ulcers, scars, scales, etc. 
Macules occur in chloasma, eczema, erysipelas, 
roseola, rubeola, scarlatina, rotheln, erythema, 
ephelis, leukoderma, melanoderma, tinea versi- 
color, syphilis, xanthoma, purpura, naevus pig- 
mentosus, and morphea. When a large portion 
or the entire skin is involved by change of color, 
it is known as a discoloration: such, for example, as 
is seen in Addison's disease, leprosy, and argyria. 
Papules are observed in acne, milium, comedo, 
eczema, lichen, prurigo, in certain kinds of purpura 
and urticaria, and in variola, keratosis pilaris, 
ichthyosis, and miliaria papulosa. The eruptions 
of measles and rotheln are really maculopapular 
in character. In syphilis the papule is often 
surmounted by a scale. 
Tubercles are found in connection with syphilis, 
leprosy, parasitic sycosis, acne, molluscum epi- 
theliale, and lupus. 
Tumors exist in carcinoma, sarcoma, syphilis, 
elephantiasis, angioma, keloid, lipoma, fibroma, 
and erythema nodosum. 
Vesicles are present in eczema, herpes, vaccinia, 
sudamina, miliaria, varicella, dermatitis, dysidro- 
sis, scabies; vesicopustules are observed in impetigo 
contagiosa, the vesicular syphilid, etc. 
Blebs occur in pemphigus, hydroa, erysipelas, 
herpes iris, leprosy, syphilis, and dermatitis. 
Pustules are encountered in acne, variola, 
ecthyma, equinia, impetigo, scabies, syphilis, 
sycosis, dermatitis, and pustula maligna. 
Wheals are found in connection with irritable 
states of the skin, such as occur from the bites of 
insects, and most typically in urticaria, and also 
in some degree with purpura and erythema 
multiforme. 
Scales are observed in psoriasis, eczema, pityriasis 
rubra, exfoliative dermatitis, scarlet fever, measles, 
seborrhea, the vegetable parasitic affections, and 
ichthyosis. SKIN-DISEASES, DIAGNOSIS 
SKIN-DISEASES, DIAGNOSIS 
Crusts are to be found in eczema, syphilis, 
scabies, ecthyma, scrofuloderma, leprosy, syph- 
ilis, impetigo, carcinoma, seborrhea, herpes 
zoster, and sycosis. 
Fissures occur in eczema, psoriasis, syphilis, 
ichthyosis, verruca. 
Excoriations are to be seen in pruriginous 
disorders, such as eczema, pruritus, pediculosis, 
scabies, etc. 
Ulcers appear as sequels to the lesions of syphilis, 
lupus, boils, carbuncles, eczema, herpes zoster, 
scrofuloderma, epithelioma, sarcoma. 
Scars come in the wake of ulcerative skin- 
diseases: e. g., lupus vulgaris, syphilis, and lupus 
erythematosus. 
Having now closely observed all that the eye, 
the touch, the sense of smell, etc., can reveal- 
in other words, having made, free from precon- 
always exempt, except in infants. Erythema mul- 
tiforme attacks the face, the neck, and the backs 
of the hands and feet. Erythema nodosum is usu- 
ally situated on the anterior surfaces of the tibias. 
The proneness of common affections to attack 
special localities is indicated in the following list: 
Scalp.-Eczema, ringworm, pediculosis capitis, 
favus, seborrhea, alopecia areata. 
Face.-Acne, eczema, lupus vulgaris, lupus 
erythematosus, syphilis, impetigo, sycosis. 
Chest.-Tinea versicolor, seborrheic eczema, 
macular syphiloderm, acne. 
Shoulders and Back.-Acne, carbuncle, pedicu- 
losis corporis. 
Buttocks.-Furuncles, scabies, congenital syph- 
ilis, eczema intertrigo. 
Genitals.-Eczema, pruritus, herpes simplex, 
scabies, syphilis. 
Tumor 
Wheal 
Bleb 
Tubercle 
Pustule 
Vesicle 
Papule 
Macule 
Scar 
Ulcer 
Fissure 
Excoriation 
Scale 
Crust 
Diagram of Skin-lesions. 
ceived notions, a thorough study of the objective 
symptoms present-we are better prepared to 
ascertain the general history of the case, to obtain 
an account of the patient's own sensations, and, 
finally, to make use of the various collateral 
methods of diagnosis that science has placed at 
our disposal. 
Locality.-Many diseases have distinct predilec- 
tions for special localities. Psoriasis elects the 
scalp and the extensor surfaces of the elbows and 
knees. Eczema may occur anywhere, but pre- 
fers the flexor surfaces. The excoriations of pedic- 
ulosis corporis are seen across the shoulder-blades 
and around the waist. Acne attacks the face and 
chest. The lesions of scabies are quite constantly 
present on the webs and sides of the fingers, the 
flexor surfaces of the wrists, the anterior and 
posterior axillary folds, the nipples, the umbilicus, 
the penis, the buttocks, the insides of the thighs 
and legs, and the toes (in infants). The face is 
Lower Extremities.-Purpura, ecthyma, eczema 
rubrum, erythema nodosum. 
Age, Sex, and Social Condition.-Some diseases 
of the skin are more prone to attack children than 
adults, and vice versa. Epithelioma usually 
appears first in middle or advanced life, while lupus 
vulgaris nearly always dates from childhood. 
Neither acne nor tinea versicolor is common in 
children, but ringworm of the scalp shows a pre- 
dilection for that age and usually spares the adult. 
Ichthyosis is practically congenital. Lupus ery- 
thematosus is more frequent in women, and 
epithelioma of the lower lip is generally an affec- 
tion of the male. 
A knowledge of the occupation is sometimes a 
help in diagnosis. Bakers, grocers, bricklayers, 
plasterers, and barkeepers suffer from eczema, and 
artisans who handle chemicals and other irritants 
exhibit various grades of dermatitis. Hostlers 
may contract glanders, and wool-sorters become SKIN-GRAFTING 
SKULL, DISEASES 
infected with anthrax. Pediculosis is more com- 
mon in the poor and unclean than in the upper 
classes of society. 
Antecedent History.-The past history of the 
case will inform us as to former attacks of cutane- 
ous or other diseases; and if the information is 
judiciously elicited, may throw much light on the 
present condition. This is of prime importance, 
especially in syphilis. 
General Symptoms.-The general symptoms of 
the patient must not be neglected. His facial 
expression, his gait, the color of his skin and con- 
junctivae, the state of the tongue, stomach, and 
bowels, etc., must be thoroughly investigated. 
The thermometer will show the body temperature, 
and microscopic and chemic investigation will 
determine the condition of the blood and urinary 
secretion, thus proving or disproving the existence 
of diabetes, nephritis, and malaria, each of which 
may be potent factors in the etiology. 
Microscope.-Aside from the employment of the 
microscope in the conditions just mentioned, this 
instrument is an invaluable aid in dermatologic 
practice. With it the character of tumors may be 
determined and information furnished as to the 
nature of obscure pathologic processes. It is of 
especial utility in recognizing the presence of fungi 
or of animal parasites, and in the investigation of 
the rapidly extending class of bacillary diseases. 
Drug and Feigned Eruptions.-The ingestion of 
various drugs produces in many persons diverse 
lesions of the skin, and a careful inquiry should 
always be made in that direction. The same 
observation may be applied in regard to certain 
foods: e. g., urticarial and erythematous rashes 
are often due to the eating of strawberries or buck- 
wheat, and eczemas are sometimes at least indi- 
rectly connected with the free eating of oatmeal. 
Many plants set up severe dermatitis, and heat and 
cold and the X-rays are also responsible for similar 
conditions. The physician should also be fully 
aware that feigned or artificial eruptions are not 
infrequently produced upon themselves by hys- 
terics and malingerers. See Drug Eruptions. 
Subjective Symptoms.-The merely subjective 
symptoms of a patient are not of paramount im- 
portance in diagnosis; still, one must not put aside 
as of no importance the statements of intelligent 
persons in matters relating to their own experiences 
of pain, itching, burning, or other sensations. 
Very often such statements may be verified by the 
condition of the integument itself; for example, if 
itching is severe, the presence of scratch marks 
will testify to its existence. 
SKIN-GRAFTING.-See Plastic Surgery. 
SKULL, DISEASES. Hypertrophy.-In ostitis 
deformans the vault of the cranium is usually 
immensely thickened. The inner surface becomes 
irregular, and is marked all over by arborescent 
grooves; the outer surface remains smooth and 
even; the diploe disappears, and on section the 
bone is hard and dense, like ivory. Beyond a 
gradual increase in the circumference of the head, 
it does not appear to give rise to any symptoms; 
no treatment is of any avail. Other forms of 
enlargement are described under Bones (Diseases). 
Craniotabes.-A peculiar form of atrophy of the 
inner table, known as craniotabes, is occasionally 
met in infants suffering from rickets. It affects 
especially the posterior inferior angles of the 
parietal bones and the tabular part of the occipital 
bone, probably because of the recumbent position 
of the child, for a certain flattening of that part of 
the head is not infrequently noticed at the same 
time; and in one or two instances in which the 
disease existed before birth, a similar change has 
been found on the inner surface of the vertex. 
The sulci for the cerebral convolutions are un- 
usually distinct, and here and there are marked 
in their course by little conic pits, which in some 
places are so deep that nothing but a parchment- 
like layer of dura mater and pericranium is left; 
the whole thickness of the bone is absorbed. 
Sometimes, in addition, there is a granular deposit 
of new bone under the pericranium on the outer 
surface, and occasionally a very considerable 
amount around the fontanels and along the 
sutures-enough to be felt plainly through the 
scalp. In all probability it is due to the effect of 
continued pressure acting on softened hyper- 
vascular bone. It certainly may occur independ- 
ent of hereditary syphilis, although it is often 
associated with it (e. g., Parrot's nodes), and a few 
instances are recorded in which other evidence of 
rickets was unusually slight. The diagnosis can 
only be made in well-marked cases by the peculiar 
parchment-like yielding on pressure with the 
fingers. No special treatment is required. 
Caries and necrosis of the bones of the cranium 
are not uncommon. They are generally the result 
of syphilitic periostitis or injury, or, very rarely, 
of tubercle or fevers. The external table is the 
most often affected; but whether the external or 
the internal table is involved, the disease seldom 
extends beyond the diploe, as the two tables have 
a distinct blood supply. At times, however, 
complete perforation of the skull occurs. Caries 
and necrosis in this situation are likely to be fol- 
lowed by septic or infective inflammation of the 
diploe and its consequences; by suppuration 
between the bone and dura mater; by meningitis 
and abscess of the brain; or by thickening of the 
dura mater, resulting in persistent headache or 
even in epilepsy. When the skull is completely 
perforated, the hole is not filled up by bone; and 
when necrosis occurs, the sequestrum is not in- 
vaginated. 
Treatment.-Beyond keeping the parts aseptic, 
providing free exit for the discharges, and remov- 
ing loose sequestra, little, as a rule, is required. 
Should pus collect between the bone and dura 
mater, it must be released by the trephine; and a 
portion of necrosed inner table may also require 
the trephine for its removal. Appropriate con- 
stitutional remedies for syphilis or tubercle will, 
of course, also be necessary. 
Meningocele and encephalocele are rare congen- 
ital tumors, formed by a profusion of the mem- 
branes of the brain through an unossified part of 
the skull. They are believed to be dependent upon 
hydrocephalus, the excess of fluid in the sub- 
arachnoid space or in the ventricles of the brain SKULL, DISEASES 
leading respectively to a profusion of the mem- 
branes alone {meningocele), or of the brain also 
{encephalocele). In the latter instance the dilated 
ventricle may extend into the protuding portion 
of the brain, a condition further distinguished as 
hy dr encephalocele. The protrusion is most com- 
mon in the occipital region, just behind the fora- 
men magnum, between the four centers from 
which this part of the occipital bone is ossified; 
next, at the root of the nose, between the frontal 
and nasal bones; but it may occur in any situation 
in the course of the sutures, and may even project 
into the nasal fossae or into the pharynx. 
Symptoms.-In the occipital region these tumors 
are generally pedunculated and of large size- 
sometimes nearly as large as the child's head; 
at the root of the nose they are usually small and 
sessile. The skin covering them is generally 
normal. They swell up when the child cries, 
and can be completely or partially reduced on 
pressure, the reduction sometimes producing 
convulsions or other brain symptoms. When they 
contain fluid only {meningocele'), they are soft, 
fluctuating, translucent, and completely reducible 
on pressure; they rarely pulsate, and are generally 
pedunculated. When they contain brain matter 
{encephalocele), they are doughy, nonfluctuating, 
opaque, and only partially reducible; they pulsate, 
and are usually sessile. They may be mistaken for 
other tumors of the scalp, but especially for con- 
genital dermoid cysts and degenerative naevi. 
However, their intimate connection with the bone, 
their situation in the course of the sutures, and their 
partial or complete reducibility, together with the 
facts that they swell up on expiratory efforts and 
occasionally pulsate synchronously with the brain, 
will usually serve for their diagnosis. Further, 
the hole in the skull may at times be detected and 
brain symptoms may be produced by pressure. 
Treatment.-As a rule, they should be let alone, 
or merely supported by a pad or bandage. A 
meningocele, when pedunculated, and apparently 
communicating with the interior of the cranium 
by a small aperture only, may be injected with 
Morton's fluid, or, under exceptional circumstances 
excised. 
Fungous tumors, generally of a sarcomatous 
nature, and springing either from the tissues of 
the scalp or pericranium, or from the diploe or 
dura mater and then penetrating the bone, are 
occasionally met, and may be mistaken for in- 
flammatory affections of the pericranium or bone, 
or for syphilitic gummata. Their rapid growth, 
resistance to syphilitic remedies, the escape 
of blood only on puncture, and the concomitant 
loss of weight and strength of the patient, will 
usually serve to distinguish them; but an explor- 
atory incision may in some cases be necessary 
to clear up the diagnosis. Secondary tumors 
which pulsate and have the structure of thyroid 
gland tissue are also occasionally met in cases of 
malignant goiter. 
Treatment.-When there is no evidence of dis- 
semination, and the tumor is small and fairly 
circumscribed, it may be removed. When grow- 
ing from the scalp, this can usually be done with- 
SKULL, FRACTURES 
out much difficulty; but when the growth arises 
from the bone or dura mater, a much more serious 
operation will, of course, be required, since a 
considerable portion of the skull will have to be 
cut away and the dura mater probably opened. It 
need hardly be said that the strictest antiseptic 
precautions must be observed (Walsham). 
Osteomata.-Those tumors growing from the 
outer table are sometimes called exostoses; those 
from the inner table and the diploe, enostoses. 
Most of the latter are, however, inflammatory, 
and probably syphilitic. Cancellous exostoses 
upon the cranium are rare; ivory exostoses are more 
common, growing chiefly from the frontal bone 
and in the external auditory meatus. Sometimes 
they are multiple and symmetric. As a rule, 
they are of very slow growth, and require no treat- 
ment; but when they grow in the frontal sinus, 
they may cause the most fearful disfigurement from 
displacement of the eyeball, or even more serious 
symptoms from pressure upon the brain; while in 
the ear they may lead to deafness, and ultimately to 
complete obstruction of the meatus, with its conse- 
quences (acute suppurative ostitis and meningitis), 
if the secretion collects behind and decomposes. 
Fortunately, it frequently happens that the necks 
of these growths are much more slender than 
would be imagined from their size, so that they 
have even been known to break off. As a rule, 
they can be detached with a drill fitted to a surgical 
engine; but very great care is required in the 
selection of proper instruments. In one or two 
instances the growths have detached them- 
selves, like the antlers of a stag, the vascular 
canals in the neck gradually becoming smaller 
and smaller until at length the blood supply is 
altogether cut off. 
SKULL, FRACTURES.-Fractures of the skull 
are usually due to direct violence. The vault of 
the cranium generally receives the blow, and 
hence is most often fractured. If, however, the 
force is diffused over a wide area, the skull is 
compressed, the most inelastic and unyielding 
part gives way, and a fissure is produced which 
generally runs across the base as well as the vault. 
Simple Fractures of the Vault.-Of themselves, 
simple fractures of the vault are of little or no con- 
sequence: contusions, fissures, and fractures 
without displacement do not admit of proof, and 
even when the bone is comminuted and the depres- 
sion considerable, the diagnosis is often only a 
conjecture, owing to the amount of blood extrav- 
asated. Their gravity arises from the fact that 
serious injury to important structures is so often 
associated with them. Concussion or contusion 
of the brain, hemorrhage between the membranes, 
or, especially if the course of the fissure traverses 
the middle meningeal artery, between the dura 
mater and the bone, rupture of the venous sinuses, 
and laceration of the membranes are of frequent 
occurrence after simple fractures; more rarely 
the contents of the cranium (the cerebrospinal 
fluid at least) find their way out, and form a soft, 
fluctuating, and pulsating swelling underneath 
the aponeurosis-cephalhydrocele. Later, espe- 
cially in cases in which the bone is severely contused. SKULL, FRACTURES 
SKULL, FRACTURES 
inflammation may set in, although it is very rare in 
comparison with compound fractures. It may 
be either acute or chronic. 
Compound Fractures of the Vault.-In the 
majority of instances the nature of the injury can 
be seen at once. There is a fissure, appearing as 
a thin, red line, out of which blood continues to 
ooze, contrasting with the white bone around, 
or the bone is plainly comminuted and driven in, 
or the broken edge of a knife or other foreign 
body can be seen upon the surface. The wound 
must be carefully and thoroughly explored with 
the finger, and its extent and the depth and char- 
acter of the displacement must be made out as 
accurately as possible, especially in the case of 
punctured wounds. 
Serious complications are much more common in 
compound fractures. The more nearly a fracture 
approaches the punctured form, the more danger- 
ous it becomes; it does not matter so much if the 
depression is wide and extensive, or if, owing to 
the softness and elasticity of the bones, there is 
little or no splintering; the dura mater is not 
injured, and symptoms of compression, merely 
from displaced bone, are exceedingly rare; but 
when the inner opening is fringed with a circle of 
little spikes projecting vertically inward, and 
tearing and irritating the membranes and the 
brain, inflammation is almost certain. In addition 
compound fractures are always exposed to the 
risk of decomposition. Blood is extravasated into 
the diploe, and between the dura mater and the 
bone; the fracture is often comminuted; there are 
numerous little spaces and fissures between 
the fragments which cannot drain, and the wound 
is frequently filled with dirt and other foreign 
substances. Under these circumstances, unless 
steps are taken to prevent it, inflammation must 
follow, and though fortunately it often remains 
limited to the wound and merely causes necrosis 
of the broken fragments, it may at any moment 
spread into the surrounding bone, or, especially 
if the dura mater has been pricked, into the mem- 
branes of the brain, and set up fatal meningitis. 
Treatment. Simple Fractures.-Unless there 
are definite symptoms of compression, either 
growing worse or refusing to clear up, nothing 
should be done. But if associated with concus- 
sion and contusion of the brain, the patient must 
be placed in a darkened room with the head 
shaved, and an ice-bag, or, better, Leiter's coil, 
applied; every source of irritation or excitement 
should be excluded, the bowels should be opened, 
preferably with a calomel purge, and nothing but 
the simplest diet allowed. Rest in bed must be 
strictly enforced for at least 3 weeks, and the 
patient must be carefully watched for months. 
The great fear during the first few days is that 
hyperemia and inflammation of the brain may 
occur; after that the chief risk comes from the 
bone, which may inflame and cause necrosis, 
meningitis, or pyemia; still later, even years after, 
symptoms of cerebral irritation may make their 
appearance, sometimes merely undue excitability 
or fits of temper, especially if there is any indiscre- 
tion in diet or abuse of stimulants; occasionally, 
but fortunately very rarely, more serious disturb- 
ance, such as epilepsy and even insanity. 
Compound Fractures.-The wound in the soft 
parts should be treated as already described; the 
hair should be shaved off, the scalp well washed, the 
hemorrhage arrested, foreign matter and dirt 
carefully removed, and then all the part that has 
been exposed thoroughly washed out with cor- 
rosive sublimate or some other antiseptic. It 
should then be well dried, the edges dusted over 
with iodoform and brought together with sutures 
(catgut is especially useful when there is no ten- 
sion), leaving suitable openings for the escape of 
the lymph, and, if necessary, one or two tubes may 
be inserted. Then it should be carefully covered 
over with a thick layer of some dressing sufficiently 
absorbent to soak up any discharge at once, and 
bandaged to avoid displacement and secure rest. 
Simple linear fissures, not depressed and not caused 
by the impact of a sharp weapon, may be covered in 
at once, the pericranium being replaced if it is torn 
off. There is no splintering in such a case, no fear 
of spicules irritating the dura mater and the brain, 
and the sooner the fracture is converted into a 
simple one, the less the risk of decomposition and 
suppuration. Punctured fractures, on the other 
hand, should always be trephined, the wound in 
the outer table being included in the circle of the 
instrument. It is impossible to ascertain the con- 
dition of the inner table; in nearly every case it is 
"starred" and the splinters driven inward; the 
operation adds nothing to the gravity of the case, 
and deep punctured wounds passing through strata 
of different consistence can neither be cleaned nor 
drained. 
In compound depressed fractures portions of 
bone that are detached or loose or driven into the 
substance of the dura mater must be picked out, 
avoiding any unnecessary violence or persistence. 
If there are symptoms of compression, or if the size 
and depth of the wound make it probable that the 
inner table is splintered, the bone must be elevated 
and, if necessary, part of a circle removed with the 
trephine, the pin resting on the uninjured margin. 
See Brain (Injuries). 
Fracture of the base of the skull is sometimes the 
result of direct violence-when, for example, a re- 
volver is discharged into the mouth, or a stick is 
forced through the roof of the orbit, or the condyle 
of the jaw is driven through the glenoid fossa. More 
often it is caused by a fissure extending from the 
vault. The fracture starts from the point that is 
struck, and generally passes across the base of the 
corresponding fossa, sometimes when the force 
is great involving more than one. The middle 
fossa suffers the most frequently, as may be ex- 
pected, and a very common course for the fissure 
to take is across the petrous portion of the temporal 
bone and the internal auditory meatus. Occasion- 
ally it is produced in other ways. The skull, for 
example, may be driven down on the vertebral 
column, just as a hammer-head is forced onto the 
shaft, with such violence as to break the bone 
around the foramen magnum; or, as it falls upon 
the head, the vertebral column may be driven 
against the skull. In fracture by contre-coup the SKULL, SURGERY 
SKULL, SURGERY 
injury is on the opposite side of the head, at the 
other end of the diameter. The orbital plate of 
the frontal bone, for example, is sometimes fis- 
sured from a fall upon the occipital region. The 
skull is suddenly shortened in its anteroposterior 
diameter, and correspondingly widened in its lat- 
eral and vertical ones; both the frontal and the 
occipital regions are flattened out; but thejf ormer, 
being the thinner, more brittle, and less regular 
in its elasticity, gives way first. It must not be 
forgotten that fractures extending into the ear, 
nose, and pharynx are really compound. 
Symptoms.-Sometimes there are no distinc- 
tive signs, and the condition is overlooked. 
It is often confused with drunkenness. Gen- 
erally, however, there are present the symp- 
toms of compression or other severe lesion of 
the brain. The signs considered especially 
diagnostic are (1) the escape of cerebrospinal 
fluid from the ear, nose, or mouth, or from an 
open wound if it exists; (2) the similar escape 
of blood; (3) effusions of blood under the con- 
junctiva, about the mastoid process or sub- 
occipital region; (4) injury of one or more cra- 
nial nerves. 
Prognosis is always grave, the cases gener- 
ally, but not always, terminating fatally from 
concomitant injury or inflammation of the 
brain. 
Treatment.-Fractures of the base of the 
skull must be treated in the same way as frac- 
tures of the vault; the brain is always severely 
injured, and the greatest care must be taken 
to ward off any source of irritation. If the crib- 
riform plate of the ethmoid is comminuted, 
an attempt should be made to remove the frag- 
ments, either through the orbit or the nose, for 
fear of the dura mater being injured, and to in- 
sure more perfect drainage. The discharge is 
certain to become purulent-unless drained 
and antiseptically irrigated-and is usually ex- 
ceedingly offensive, especially if the injury is 
followed by necrosis. In the case of the ear, the 
meatus should be gently syringed out with an an- 
tiseptic, and then covered with a large pad of 
absorbent cotton, renewed as often as required. 
The fracture is compound, but meningitis rarely 
follows. Callus is scarcely ever thrown out, the 
parts lie absolutely quiet, and there is no irritation; 
in many cases union is by fibrous tissue only; and 
the edges of the fracture become smoothed down 
and absorbed to some extent, so that the fissure, 
when the skull is macerated, appears much larger 
than it really was. See Skull (Surgery). 
SKULL, SURGERY.-Conditions calling for cra- 
nial surgery are cerebral abscess, tumors, injuries, 
hydrocephalus, idiocy, general paralysis, and 
severe cephalalgia and intracranial hemorrhage. 
The tumors are glioma, psammoma, localized 
tubercular lesions, syphilitic scars that drugs 
cannot absorb, scar tissue and cystic formations 
following injury, and parasitic cysts. Sarco- 
matous and carcinomatous growths are usually 
too extensive for removal, or are multiple from 
the first. Moreover, since they have no capsule 
they are not sufficiently distinguishable from the 
surrounding brain-substance to insure their com- 
plete excision and their nonreturn in the scar. 
Symptoms.-The chief signs of a cerebral tumor 
are vomiting, persistent headache, optic neuritis, 
localized spasms or paralysis, and epileptiform 
convulsions, and convulsive seizures usually start- 
ing in the part connected with the cortical area 
involved in the growth (Jacksonian epilepsy). 
Localization.-Among the symptoms that may 
enable the surgeon to localize the growth are the 
following: (1) If at the beginning of the epilepti- 
form fit there are: (a) Pain, peculiar sensation, 
Areas on the Convex Surface of the Cerebrum.-{Horsley 
and Russell.) 
flexion, or hyperextension of the great toe, a 
lesion of the leg area on the opposite side of the 
cortex about the upper end of the fissure of 
Rolando close to the middle line is indicated; 
(b) movements of the shoulder, a lesion near 
the upper part and in front of the fissure; (c) 
flexion of the thumb, a lesion about the genu of 
the fissure; (d) turning of the head and eyes to 
the opposite side, a lesion about the hinder portion 
of the superior and middle frontal convolutions; 
(e) movements of the mouth and tongue, a lesion 
about the lower end of the fissure of Rolando. 
An epileptiform movement starting in one of these 
parts may be followed by loss of power in the 
part for some time after the fit. (2) Aphasia 
indicates a lesion of Broca's convolution. (3) 
Loss of half the fields of vision in both eyes points 
to a lesion of the angular gyrus of the side opposite 
to the lost fields of vision. (4) Loss of hearing 
suggests a lesion of the two upper temporosphenoid 
lobes. (5) Aid .to localization may also be de- 
rived from the involvement of the cranial nerves 
(Walsham). 
When, from a consideration of the foregoing 
symptoms, a tumor or new growth is believed to 
be fairly circumscribed and in an accessible situa- 
tion the skull should be trephined, a sufficient por- 
tion of the bone removed to fully expose the 
growth, by a Hey's saw, Gigli saw, Hoffmann's, 
Keen's, Dahlgren's or Hudson's forceps, or the sur- 
gical engine, and the growth cut away by making SKULL, SURGERY 
SKULL, SURGERY 
perpendicular incisions into the brain around it, 
and raising it by means of a sharp spoon. Many 
experienced brain surgeons, notably Horsley and 
Krause, make use of the osteoplastic flap method, 
which consists in raising a flap composed of both 
soft tissues and bone, the latter being cut through 
along the line through which the former are in- 
cised, and the base then fractured by leverage 
and raised with the superficial tissues. It is 
frequently advisable to do the operation in two 
stages, allowing an interval of six to fourteen days 
between the formation of the flap and the removal 
of the tumor. When the operation is thus done, 
the flap is replaced and held in position by means 
of deep sutures. Whenever the operation is 
begun with the intention of completing it at one 
sitting a rim of bone at least one centimeter in 
initial movements may be exposed, the exact 
spot for the initial movements found by ex- 
citing the brain with the faradic current, and this 
area of the cortex excised. After such an opera- 
tion a diminution in the number of fits as well as 
an improvement in the health of the patient may 
be expected. 
In general paralysis trephining in a few cases 
has been of some benefit in the early stages of the 
disease. Thus the hallucinations have disap- 
peared, and the patient has so far improved as to 
be fit to be set at liberty. 
In severe cephalalgia, incapacitating the patient 
for work or preventing sleep, trephining may give 
relief. In such cases an exostosis, ta spicule of 
bone, an enlarged Pacchionian body, or a fibrous 
tumor or cyst of the dura mater has been found, 
and its removal has been followed by com- 
plete recovery. In other cases when a tu- 
mor, etc., of the brain that did not permit 
of removal has been discovered, the relief 
of pressure has freed the patient from the 
excessive pain or threatened blindness. 
Hydrocephalus, especially when accom- 
panied by fits, when progressive atrophy 
of the optic nerve threatens, or when de- 
mentia or coma supervenes, may be treated 
by tapping the ventricles at intervals and 
applying slight pressure to the skull, or, 
if this fails, by continuous drainage of the 
ventricles. 
Microcephalus combined with idiocy, due, 
it is thought, to too early synostosis of the 
cranial sutures, especially the sagittal and 
coronal, may be benefited by craniectomy- 
i. e., the removal of a strip of bone on either 
side of the middle line of the skull. The aim 
of the operation is to allow the brain, the 
development of which has been prevented 
by the early synostosis, to expand. See Cra- 
niectomy. 
Trephining.-Trephining is an operation re- 
quired for the relief of (1) injury; (2) abscess, 
especially following ear disease; (3) tumors, 
including cysts; (4) trigeminal neuralgia. After 
injury it is required for (a) All cases of compound 
depressed fractures, including punctured wounds, 
gutter fractures and grazing of the skull by bullets, 
(b) Simple or subcutaneous depressed fracture in 
children if at all marked, whenever over the region 
of the sensorimotor areas, also for depressions 
occasioned during birth which tend to cause irrita- 
tion and epilepsy, (c) Localized intracranial 
hemorrhage, particularly from rupture of the 
middle meningeal artery, (d) Signs of increasing 
intracranial tension or of suppuration, whether 
localized or not. (e) In late results of injury, 
localized pain and tenderness, and for focal 
epilepsy. If a wound of the scalp exists, it should 
be enlarged, otherwise a large semicircular flap of 
the scalp should be turned down, so that when it is 
replaced after the operation, the trephine hole is 
completely covered. The pericranium having 
been turned back from the bone, the trephine, 
with the pin protruded 1/10 of an inch, should be 
applied, and steadily worked, clearing the teeth 
Areas on the- Mesial Aspect of the Cerebrum.-(Horsley and 
Russell.) 
breadth must be cut away (Krause). In order 
to prevent bony union the blood-pressure should 
be taken at the beginning of the procedure and 
every few minutes while the surgeon is operating; 
any decided fall should be considered a danger 
signal and the operation either hastily completed 
if it be already almost done, or abandoned to be 
finished at another time. The mortality in opera- 
tions for cerebral tumors is high under all circum- 
stances, but statistics show it to be less in those 
cases in which the operation is done in two stages 
than in those in which it is completed at one 
stance. 
The removal of a portion of the cortex will be 
followed by loss of function of the area removed, 
but this will be regained to a great extent by the 
aid of the surrounding areas, especially as regards 
the coarser movements. The finer movements of 
the fingers and thumb will not be completely 
regained; hence in this region the removal of 
cortex should be as limited as is consistent with 
success. Parasitic cysts should be drained. 
In focal epilepsy, that is, epilepsy without obvi- 
ous gross lesion-when the fits become very fre- 
quent-for example, more than one an hour-and 
the mental processes are becoming further im- 
paired, the focus in the cortex representing the SLEEP, DISORDERS 
SLEEPING SICKNESS 
from time to time with an aseptic sponge or the 
brush provided for the purpose in the trephine 
case. A good groove having been formed in the 
bone, the pin should be withdrawn. When the 
diploe is reached, which may be known by the 
bone-duct being soft and red, greater caution 
must be used, and a quill or probe introduced into 
the groove at intervals to ascertain whether per- 
foration has taken place at any situation. When 
the crown of bone is loose, it should be removed 
with the sequestrum forceps, and if it is intended 
to replace it, it should be kept warm in some weak 
antiseptic solution, and at the end of the operation 
cut into small pieces and placed in the hole, and 
the flap laid down over it. If more room is neces- 
sary, the trephine hole may be enlarged by a Hey's 
History.-Sleeping sickness was known and 
described in Africa as far back as 1800 a. d. The 
disease at that time was confined to a few endemic 
areas, but of late years it has become widespread 
on account of the opening up of new areas of trade 
and travel over tropical Africa. Prior to 1903, 
the disease was known by its clinical symptoms 
only. In 1901, Forde discovered an intracellular 
protozoal organism in the blood of an Englishman, 
who had spent 6 years on the Gambia river in 
British West Africa. Dutton recognized and 
described the parasite as a new species of try- 
panosome infecting the blood of man. In 1902, 
Dutton and Todd found the parasite in 6 cases out 
of 1043 natives in the Gambia. In 1898, Brault 
had suggested that sleeping sickness might be 
caused by a trypanosome, but the relation between 
the two was not made until 1903, when Castellani 
demonstrated the trypanosome in the cerebro- 
spinal fluid of patients suffering from sleeping 
sickness. Since Castellani's discovery, the disease 
has been investigated by numerous Commissions, 
whose reports cover in great detail every phase of 
the subject. 
Geographical Distribution.-Sleeping sickness 
has not been discovered outside of equatorial 
Africa. The limits of the disease on the west 
coast are the Senegal on the north and Mos- 
samedes in Portuguese West Africa on the south. 
Along this coastal territory, the distribution is 
decidedly irregular. In some places a large per- 
centage of the native inhabitants are infected, 
while other districts are comparatively free. The 
basins of the Senegal, Gambia, Niger, Congo, and 
head waters of the Nile rivers are infected. No 
cases have been reported from the Zambesi. In 
the interior whole tribes have been destroyed. 
Around Lakes Albert Nyanza and Victoria Nyanza 
the majority of the native inhabitants have per- 
ished. The east coast of Africa is free from the 
disease and no cases have originated within 400 
miles of the coast. Outside of the endemic area 
both natives and Europeans have been diagnosed 
as suffering from the disease, but inquiry has 
always led to a history of residence within the 
infected area. Within this area there are many 
places endemically free. The low-lying banks of 
streams and shores of lakes of those localities, 
whose native inhabitants live near the water, 
harbor the infection in a particularly virulent form. 
In the West Indian slave trade days, there were 
many cases of sleeping sickness among the West 
African negroes imported from Africa, but the 
disease never became endemic and no cases of 
sleeping sickness are known to have occurred in 
any native born West Indians. 
Predisposing Causes.-Before any series of 
exhaustive observations had been made, it was 
believed that the natives alone were liable to 
infection. This has been disproved and it is now 
known that all races and both sexes are equally 
liable, providing exposure to the infecting agent 
has taken place. The white inhabitants of an 
infected district are less liable to contract the 
disease than a native on account of the protection 
rendered by his clothing and different mode of life, 
saw, Hoffman's or Keen's forceps, or by the sur- 
gical engine. The strictest antiseptic precautions 
should be used throughout. Thus, the whole 
scalp should be shaved, and washed with soap and 
hot water, then with ether, turpentine, or am- 
monia, to remove all grease, and afterw'ard with 
perchlorid of mercury or other antiseptic. Heal- 
ing by first intention should be obtained if possible 
by accurately uniting the wound-except perhaps 
at its lowest part, which may be left open for 
drainage-and by applying a dry antiseptic 
dressing, and over it an ice-bag to prevent inflam- 
mation. The trephine should not be applied, as a 
rule, over a suture, an air or venous sinus, or over 
the middle meningeal artery, unless the operation 
is undertaken with a view to secure that vessel. 
The conic trephine of Walsham will be found a 
safer instrument than that in ordinary use, as 
with it the dura mater is less likely to be injured, 
and the handle also is more comfortable to work 
with. It can now be had with a metal handle and 
the improved button-pin. Before trephining for 
the removal of a cerebral tumor morphin should be 
given, as it causes contraction of the small blood- 
vessels, and so has a tendency to lessen the hemor- 
rhage. See Craniometric Points. 
SLEEP, DISORDERS.-See Insomnia, Night- 
mare, Somnambulism, Sleeping Sickness, etc. 
SLEEP, TWILIGHT.-See Twilight Sleep. 
SLEEPING SICKNESS, Definition.-The human 
trypanosomiasis endemic in Africa, the terminal 
stage of which is characterized by somnolence, 
torpor, and coma. SLEEPING SICKNESS 
SLEEPING SICKNESS 
but there is a large series of cases on record now of 
the disease in both white men and white women. 
Age seems to have no influence upon liability to 
infection, and among natives of an infected area, 
all ages are seen suffering with the disease. 
Etiology.-Prior to the establishment of the fact 
that sleeping sickness is the terminal stage of 
human trypanosomiasis, many theories had been 
advanced to explain the disease, and it had been 
considered at various times by different observers, 
a manifestation of bacterial, filarial, strongyloides, 
and hook-worm infections. Chronic food poison- 
ing had also been incriminated. Castellani's 
discovery in 1903, of the trypanosome in the 
cerebrospinal fluid of sleeping sickness patients 
has been confirmed by many workers, and now 
the entire cycle of infection with the transmitt- 
ing agent is known, with the exception of a few 
minor points. 
The Parasite.-After the recognition of the 
parasite in Forde's case it was named trypanosoma 
gambiense. Nepveu had first seen the parasite 
in the blood of man, but his description is imper- 
fect. Castellani gives its dimensions as from 
16 to 24 microns long, and from 2 to 5 microns 
broad. Anteriorly it is either pointed or rounded 
and along one border is an undulating membrane, 
which is a thickening of the ectoplasm. This is 
continued posteriorly into a free flagellum. The 
origin of the undulating membrane takes place 
from a minute spot of nuclear material of oval 
shape, called the kinetonucleus, situated near the 
anterior end of the trypanosome. About the 
middle of the body of the parasite is an oval mass 
of nuclear material, irregularly shaped, called the 
trophonucleus. A few chromatin granules may 
be seen posterior to the trophonucleus, and the 
cytoplasm is continued in a narrow diminishing 
band for some distance along the flagellum. In 
Castellani's report in the Reports of the Royal 
Society on Sleeping Sickness are pictured besides 
the ordinary forms, multinucleate, polyflagellate, 
and nonflagellate forms. 
Occurrence of Parasite in Man.-The main facts 
of the life cycle of the parasite have been worked 
out but there are still a number of unknown points. 
In man the trypanosome is found in the peripheral 
circulation, the cerebrospinal fluid, and the lymph 
nodes of cases of sleeping sickness at various times 
during the progress of the disease. The majority 
of observers believe that the parasite is found in 
the peripheral circulation and lymph glands during 
the early stages (the so-called trypanosomatic 
fever); and that the invasion of the cerebrospinal 
fluid marks the beginning of the later stages. 
Various methods have been devised for demon- 
stration of the trypanosome in the blood of man. 
Unless the trypanosomes are quite numerous they 
will be overlooked in the ordinary fresh blood 
preparations; the use of a large hanging drop, 
searching from 10 to 15 minutes, will give positive 
results in a larger percentage of cases in the early 
stages. The trypanosome may be located first 
with the low power of the microscope by the move- 
ments of the red blood cells as they are lashed by 
the flagellum of the parasite. Further investiga- 
tion should then be made with the high power. 
The surest method of demonstration in fresh blood 
preparations is by the use of the centrifuge. 
About 10 c.c. of blood are drawn in the usual man- 
ner from a vein at the bend of the elbow. This is 
drawn in 1 percent sodium citrate in normal salt 
solution to prevent coagulation, centrifuged three 
times and the third or fourth residue examined. 
For staining blood preparations the various modi- 
fications of the Romanowsky stains give very 
good results. Koch, in his work on Lake Nyanza 
used a heavy drop of blood, which he stained with 
a dilute solution of Giemsa's stain. In the hands 
of experts, this is a very reliable method, but one 
or two trypanosomes may be overlooked on 
account of their being concealed by red blood cells 
and fibrin. During the latter stages of the disease, 
the trypanosomes may be demonstrated by exam- 
ination of the cerebrospinal fluid obtained by 
lumbar puncture. In examining the cerebro- 
spinal fluid, fresh and stained preparations are 
made and if these are negative, the fluid is centri- 
fuged and the sediment examined. The lymph 
nodes and channels contain the trypanosomes at a 
very early stage of the disease and puncture of an 
enlarged lymph gland is the most certain method 
of demonstrating the parasite. A technic of gland 
puncture used by Grieg and Gray has given most 
satisfactory results. An enlarged gland of the 
posterior cervical chain is grasped between the 
thumb and index-finger and punctured by a sterile 
hypodermic needle. Then the barrel of the 
instrument is placed on the needle and the latter 
withdrawn. The drop of gland juice may thus be 
expressed upon a slide and examined as a fresh or 
stained preparation. Artificial culture of the 
trypanosome of sleeping sickness has not been 
successful, although they were kept going for 68 
days by Thomas and Breinl. 
The Transmitting Agent.-After the discovery 
that the trypanosome was the cause of sleeping 
sickness, it was soon noted that the distribution of 
the disease in the endemic foci was limited to those 
areas in which a certain species of the tsetse fly 
was found. There are ten species of this fly in 
Africa, but only one species, Glossina palpalis, has 
been proved to be the transmitting agent of the 
Trypanosoma gambiense of man. In appearance, 
Glossina palpalis is a dark colored fly, about 8 to 
12 mm. long. A point of recognition is the ar- 
rangement of the fly's wings in the resting position. 
They overlap like a pair of scissors. This point 
differentiates the tsetse fly from other blood-suck- 
ing diptera with which it is associated. 
Distribution.-The tsetse flies are limited to 
Africa. The Glossina palpalis is found along the 
west coast from about 13° to 15° south of the 
equator. In the interior it is not found farther 
north than 8° in the Anglo-Egyptian Soudan, nor 
farther south than 12° on the Luapula river in 
northeast Rhodesia. It is found in Angola, 
Congo State, The Gambia, Gold Coast, Ivory 
Coast, Lagos, North and South Nigeria, Prince's 
Island, Sierra Leone, Anglo-Egyptian Soudan, 
Uganda, Northeast Rhodesia, Togoland, Senegal, 
Niger, French Guinea, French Congo, Dahomey, SLEEPING SICKNESS 
SLEEPING SICKNESS 
and the Gaboon. It is very numerous on Lakes 
Victoria Albert and Albert Edward. Lake Tan- 
ganyika and Mveru. It is not found on the east 
coast nor within approximately 400 miles of it. 
Habitat, Habits, Method of Propagation.-All of 
habitat of the fly is a loose soil, well shaded, bor- 
dering a lake, stream, or pool, with a temperature 
range of 25° to 30° C. and a high degree of humidity. 
It is not found in the dense jungle where the 
ground is always shaded nor in clear places where 
there is no shade. It has not been found above an 
Glossina Palpalis.-(Adapted from Wellcome Research 
Laboratory Reports.) 
Trypanosoma Gambiense in Human Blood.-(Schleip.) 
the glossinse are typical sanguiverous diptera, and 
they bite all mammalia. In examining the intes- 
tinal contents of a large number of Glossince 
palpales, Koch found red blood cells from croco- 
diles most frequently, and from man next. Avian 
altitude of 4000 feet. Hodges considered that 
the natural range of the fly was about 30 yards 
with a following range of very long distances. 
The native boats and caravans distribute these 
flies over a wide area by mechanical transmission 
and it is by this method that human trypano- 
somiasis has been so widely spread during the 
Perivascular Infiltration of Lymphocytes in Sleeping 
Sickness.-(Mott. B. M. J., Dec. 16, 1899.) 
Forms of Trypanosoma Gambiense seen in Blood and 
Cerebrospinal Fluid.-(Adapted from Manson's 
Tropical Diseases.) 
blood was found very rarely. The flies only bite 
during the daytime from sunrise to sunset. The 
Portuguese Commission working on Prince's 
Island reported that they were less liable to bite 
during the mid part of the day, but observers in 
other parts of Africa lay no stress upon this point. 
Both male and female flies bite, and they seem to 
prefer a dark to a light surface. The optimum 
past 10 years. Dutton and Todd, on the Congo, 
believed that the natural flight of the fly was a 
considerable distance, and Roubaud on the same 
river reported that it would attack passengers on 
boats a mile from shore. The flight of the fly is 
swift and there is a buzzing sound. Clothing is a 
fairly adequate protection against the bite of the SLEEPING SICKNESS 
SLEEPING SICKNESS 
fly, but observers report that it can bite through 
socks, white drill or duck, khaki, and flannel 
shirts. There is little or no pain accompanying 
the bite, and little or no irritation follows. The 
female Glossina palpalis gives birth to a larva 
every 9 or 10 days. This larva buries itself in the 
loose soil, crevice of a tree trunk, or decaying mass 
of vegetation, and changes to the pupal stage. 
Both larv® and pupae are killed by prolonged 
exposure to water, and if shade is removed, they 
die under the direct rays of the sun. In 32 or 33 
days the pupa hatches. 
Cycle of Trypanosoma Gambiense in the Fly.- 
The French Commission working in the Congo 
believes that for the transmission of the trypano- 
some over long distances, the Glossina palpalis is 
necessary, but for the transmission from one 
individual to another, such as would take place in 
a native family inhabiting the same hut, other 
biting insects may mechanically transmit the 
trypanosome. Bruce, working with Nagana, the 
trypanosomiasis of cattle, could discover no trace 
of the trypanosomes in the proboscides of tsetse 
flies later than 1 hour after they had bitten infected 
animals. Munchin, Gray, and Tulloch found no 
trace of trypanosomes in the bodies of infected 
flies later than the third day after infection. Dur- 
ing the 3 days after infection, trypanosomes were 
found in the midgut of the fly. Kleine, working 
with Qlossina palpalis and Trypanosoma gambiense 
on experimental animals concluded that Glossina 
palpalis is a true host of the trypanosome. Some 
of the flies were able to infect laboratory animals 
immediately after biting. They lost this ability 
to transmit the trypanosome for about 18 days, 
when they were able to infect experimental ani- 
mals again. The duration of the period of infec- 
tion is unknown. Two years after the native 
population had been removed from the shores of 
Lake Victoria, the British discovered that the 
tsetse flies were still infective to experimental 
animals. There is a possibility in this case of the 
flies finding new infection in natives. If this 
source could be barred, there would remain the 
possibilities of (1) a reservoir of human trypano- 
somiasis existing in some animal, (2) the life of a 
tsetse fly extending over 2 years, (3) and hered- 
itary transmission of the trypanosome in the fly. 
Both dogs and monkeys are infective and the 
disease runs a fairly rapid course of about 2 
months in the former and about 12 months in the 
latter. In the laboratory animals, the infection 
runs a more chronic course. 
Symptoms.-For purposes of description, the 
course of the disease is divided into three stages. 
During the first stage the parasite is present in the 
peripheral circulation and in the enlarged glands; 
the second stage is marked by an invasion of the 
cerebrospinal fluid; and in the third stage, the 
symptoms of serious nervous involvement are seen. 
First Stage.-In blacks there may be no symp- 
toms. In a reported case of a European, there 
was fever, irregular in type, accompanied by 
irritability, insomnia, headache, and loss of 
strength. This persisted for 15 to 20 days, then 
there was an improvement. The fever persisted, 
however, coming on at irregular intervals, with a 
tendency to rise at night. During this stage there 
is an acceleration of the pulse, which is distinct 
from the febrile rise. The pulse rate at this 
stage is often 120. During the second and third 
months, Kerandel's sign of deep hyperesthesia is 
noted. Kerandel in describing this symptom 
said that ordinary contact with objects, such as 
would pass unnoticed in a normal individual 
caused very severe pain. In Europeans, an ery- 
thema appears which may have an irregular dis- 
tribution. This skin eruption may not be noticed 
in the blacks. Fugitive and painful patches of 
transitory edema on face and ankles may be 
present. Loss of sexual power in men, and amen- 
orrhea in women are common. Anemia, loss of 
flesh, headache, itching, may be present. Iritis 
and cyclitis have been noted and blacks complain 
of photophobia and sensations of mist. Vomiting, 
colic, bloody diarrhea may occur. Adenitis is 
sometimes absent, but in the majority of cases 
there is a painless enlargement of the cervical 
glands. Polyadenitis may be present. 
Second Stage.-The symptoms of the first stage 
are accentuated. The anemia is more pronounced, 
the headaches more frequent and severe. Patches 
of edema are more constant. The febrile attacks 
occur oftener and finally there is a daily afternoon 
rise of temperature. During the course of the 
disease, the temperature seldom arises above 103° 
F. There is a gradual change of character, with 
intellectual apathy and a tendency to drowsiness. 
Fibrillary tremors of the tongue appear, which may 
interfere with speech. Tremors in the arms, when 
extended, may be present. Zones of anesthesia 
and hyperesthesia and muscular atrophy are 
reported. There are attacks of giddiness and the 
gait may be hesitating. It is reported that during 
the first part of this stage, Romberg's sign is 
absent, later it is present, and finally the patient 
must stand upon both legs with eyes open to keep 
from falling. Martin, Guillain, and Darre de- 
scribe a medullary (spinal) and a cerebrospinal 
form, in the former there being loss of sensation 
and motion, and in the latter, mania and hallucina- 
tions. 
Third Stage.-In the final stage the nervous 
symptoms show that serious structural changes 
have taken place in the cerebrospinal axis. The 
intellectual apathy is extreme and somnolence has 
given place to torpor. There are tremors, and 
convulsions may take place similar to Jacksonian 
epilepsy. The patient lies in coma toward the end. 
The axillary temperature at this time is usually 
subnormal. Death takes place while in coma, or 
from some intercurrent disease, such as pneu- 
monia, dysentery, or tuberculosis. It is the third 
stage which gave the name sleeping sickness to the 
disease. 
Duration of the Disease.-This is uncertain. In 
one case reported, a European, there was an 
interval of about one month between known 
exposure to infection and beginning symptoms. 
The first stage may last from a few months to a 
few years. During the second and third stages, 
careful nursing will prolong fife considerably. SLEEPING SICKNESS 
SMALLPOX 
The length of life of Europeans, after definite 
symptoms appear, varies from 1 1/2 to several 
years. In untreated blacks, it may be shorter. 
Blood.-All observers agree that there is a 
relative increase in the lymphocytes. The French 
Commission reports the following as an average 
differential count: 
Polynuclears, 49.04 
Lymphocytes, 36.6 
Large mononuclears, 6.36 
Eosinophiles, 6.24 
Transitional, . 7 6 
The eosinophilia was caused by filariasis. There 
are no reports of a leukocytosis in uncomplicatted 
cases of human trypanosomiasis. 
Pathology.-Bruce reports that the gross 
appearance of the brain is fairly characteristic of 
sleeping sickness. He says that "upon removing 
the calvarium, a great deal of fluid escapes. The 
dura mater is not adherent and as a rule presents 
nothing abnormal. On reflecting it, the convolu- 
tions on the surface of the brain are found to be 
flattened and the sulci filled with opaque looking 
subarachnoid fluid, giving a ground glass appear- 
ance. The vessels on the surface are injected. 
On section, the brain appears normal, but the 
lateral ventricles are dilated and contain an 
excess of fluid." The microscopic pathology was 
worked out by Mott. He reported that the 
specific lesion was a meningoencephalitis in which 
there was a perivascular infiltration of mono- 
nuclear leukocytes around both large and small 
blood-vessels of the brain and cord. Bruce con- 
cludes that " human trypanosomiasis is essentially 
a disease of the lymphatic system, and the irrita- 
tion and proliferation of the lymphocytes is prob- 
ably due to a toxin, secreted by or contained in the 
bodies of the trypanosomes. The characteristic 
symptoms of the disease are no doubt due to the 
accumulation of these lymphocytes in the perivas- 
cular spaces of the brain, compressing the arteries 
and so interfering with the normal nutrition of the 
brain cells. The progressive weakness of the body, 
the tremulous conditions of the muscles, the feeble, 
rapid pulse, the weak voice and uncertain gait, the 
rise of temperature, would all be accounted for by 
this obstruction or interference with circulation, 
giving rise to degenerative changes in the nerve 
cells and proliferation of the neuroglia." 
Diagnosis.-A tentative diagnosis may be made 
upon the clinical symptoms; but the absolute 
diagnosis depends upon the discovery of the try- 
panosomes in the enlarged cervical glands, in the 
peripheral circulation, or cerebrospinal fluid, 
according to any of the methods described under 
the "parasite." Numerous observers have re- 
ported an autoagglutination of red blood cells in 
cases of human trypanosomiasis, and African 
workers regard this as a very suggestive sign. 
Treatment.-Besides general hygienic measures, 
which seem to prolong life only, a specific treat- 
ment with arsenical derivatives with or without 
some of the anilin dyes has been made use of. 
This specific treatment is based on animal ex- 
perimentation, some of the arsenical derivatives, 
notably atoxyl, destroying the trypanosomes in 
the blood of infected animals. Breinl states that 
the injection of atoxyl and mercury, atoxyl and 
antimony, and arsenophenylglycin will produce 
cures in infected monkeys provided careful general 
treatment is carried out. He concludes that in 
man, atoxyl by itself affects a permanent cure in 
comparatively few and exceptionally favorable 
cases of sleeping sickness. The trend of medical 
opinion inclines now to a combined treatment with 
atoxyl and mercury, salts of antimony or some of 
the anilin compounds, such as trypan-red. Nat- 
tan-Larrier gives the results of treatment of eight 
Europeans. Of those who received general treat- 
ment only, one remained well for 17 months and 
then relapsed, another had a relapse with cerebral 
symptoms, and the third remained without 
symptoms two years. Of 5 treated cases, 3 re- 
ceived weekly hypodermic injections of 0.5 G. 
of atoxyl. There were two relapses and the con- 
dition of the third is doubtful. Another case, 
which relapsed, received atoxyl by mouth and 
injections of mercury. A case treated with 
atoxyl and strychnin improved. Atoxyl occasion- 
ally causes partial or total blindness. Soamin, 
a trade name for sodiumaminophenylarsenate 
is recommended as possessing all of the beneficial 
effects of atoxyl with none of its deleterious action. 
Yet cases are reported of optic atrophy from the 
use of this drug as well. 
Prognosis.-The consensus of opinion seems to 
be that there is a slight prospect of cure provided 
the case is seen in the very earliest stages, but in 
the vast majority of cases, there is a fatal termina- 
tion that may be only temporarily halted by 
proper nursing with administration of atoxyl or 
some other arsenical derivative. 
Prophylaxis.-This may be either personal or 
general. Individuals who are obliged to enter 
the infected districts should wear clothing and 
face nets which will protect against the bites of 
the Glossin a palpalis. The British, French, 
Germans, and Portuguese are endeavoring to rid 
their African territory of sleeping sickness by 
measures, which include the segregation and 
treatment of infected natives and the destruction 
of the Glossina palpalis. The British removed 
the natives from the infected areas around the 
Victoria Nyanza and established sleeping sickness 
camps where cases might be observed and studied. 
Koch rid an island in the lake of the tsetse flies 
by deforestation. The larvae and pupae of the 
fly will not develop unless they are shaded. De- 
forestation, however, is impracticable, except in 
certain localities. Travel between infected and 
noninfected districts has been regulated, and 
there is some prospect that eventually, the disease 
may be limited to'certain foci. 
SMALLPOX (Variola).-An acute, contagious 
disease, epidemic, characterized by an eruption 
that makes its appearance first as a papule, then 
is converted into a vesicle, finally becoming pustu- 
lar, with the formation of a crust. See also Vacci- 
nation. 
Varieties.-(1) Discrete; (2) confluent; (3) 
hemorrhagic; (4) varioloid. SMALLPOX 
The period of incubation is from 7 to 12 days. 
Etiology.-The specific microorganism of small- 
pox is probably an intracellular protozoon. Uni- 
cellular bodies are formed near the nucleus of the 
epithelial cell; and its final spores are considered 
by Councilman to be the true agent of infection. 
The virulent poison seems to be more abundantly 
present in the crusts. At this stage it is most 
highly contagious, is capable of being carried by 
fomites for great distances, and has the power of 
causing the disease after long periods of time. 
The disease is modified by a previous vaccination. 
One attack generally confers immunity, but sub- 
sequent attacks may occasionally take place. 
Pathology.-The eruption consists at first of a 
small, hard, red papule, surrounded by a red 
areola. Within a short time liquefaction necrosis 
begins, forming a vesicle depressed in the center. 
The papules seem to originate in the epidermis 
immediately over the papillae; it is here that lique- 
faction necrosis occurs. At the same time there 
is an exudation of a lymphoid material, through 
which are seen threads of denucleated cells dividing 
the vesicle into distinct divisions. In the stage 
of maturation the rete malpighii is filled with 
leukocytes and the products of coagulation necro- 
sis. If the suppurative process extends through 
the cutis, scarring is inevitable. The eruption is 
very frequently seen on the soft palate and mucous 
membrane of the mouth and on the tongue. The 
red blood-corpuscles are greatly diminished; the 
leukocytes are not affected until the pustular stage; 
they are then increased. 
Internal Organs.-The lungs and spleen are con- 
gested. The liver and kidneys occasionally show 
a degree of parenchymatous degeneration. 
Symptoms and Clinical Course. Discrete Small- 
pox.-The onset is usually marked with a chill, in- 
tense frontal headache, and lumbar pains, often 
nausea and vomiting. In young children convul- 
sions are frequent. The fever rises rapidly to from 
103° to 104° F. within the first 48 hours, where it 
remains until the third or fourth day, or until the 
papular eruption appears, when it falls several de- 
grees. The eruption is first noticed about the 
forehead at the junction of hair and on the wrists. 
The pulse is rapid and full. 
The temperature remains low until about the 
eighth or ninth day, when the pustular stage arrives 
and there is a secondary rise of temperature-105° 
F. or more -proportionate to the severity of the 
attack. There is now great swelling about the 
face, and the eyelids may be entirely closed. In- 
tense pain is present over the affected area. At 
this stage a peculiar odor is detected. If the case 
terminates favorably, toward the twelfth day des- 
quamation begins with restoration of the diseased 
epidermis. 
The Eruption.-It may be said, with due allow- 
ance, that the eruption for 3 days remains a papule, 
3 days a vesicle, and 3 days a pustule. Tbe pap- 
ules are at first hard to the touch, and can be rolled 
around under the skin like a shot. The vesicle is 
depressed in the center (umbilicated) and is di- 
vided by the meshes into distinct compartments 
(loculated) which, if incised in one portion, all of 
the fluid will not escape, but only in the mesh in 
which the incision is made. 
Confluent Smallpox.-The onset is the same as in 
the discrete form-with the papules at first dis- 
crete or separate, but later run together. The 
primary rise of temperature is higher, as a rule, 
than in the discrete form; and the same is true of 
the secondary fever, which may also be very 
irregular. With the rise of secondary fever the 
suffering becomes more intense, and there may be 
delirium and stupor, with rapid pulse. 
Hemorrhagic Smallpox (Malignant Smallpox).- 
The primary symptoms are all exaggerated, and 
instead of the eruption first appearing, there are 
seen small punctiform hemorrhages about the 
groins and conjunctivae, which gradually increase 
in size until large areas are affected. Hematuria, 
hemoptysis, and hematemesis are very common. 
Death usually occurs from the fourth to the seventh 
day. In this form there is usually no distinct 
eruption. 
Varioloid.-This is a modified form of smallpox 
occurring in a person who has been previously 
vaccinated. The symptoms come on very sud- 
denly, with a rise of temperature, headache, and 
severe pains in the back. The papules, as in dis- 
crete smallpox, appear on the forehead and arms 
on the third or fourth day. As a rule, they are 
fewer in number than in discrete smallpox. The 
papules become vesicles within a day or two, then 
pustules, and finally desquamate; the whole proc- 
ess frequently is completed within a period of 5 
or 6 days. See Vaccination. 
Complications.-Bronchopneumonia (most com- 
mon), laryngitis, pleurisy, iritis, keratitis, conjunc- 
tivitis, boils, convulsions. 
Diagnosis.-With the appearance of the perfect 
papule all doubt in the diagnosis of smallpox gener- 
ally ceases. Ignorance of the inital rashes, measly 
and scarlatinal, has often led to errors of diagnosis. 
On the other hand, the resemblance of the eruption 
of measles to smallpox has also given rise to errors, 
the result of which has been no less serious; because 
in consequence, cases of measles have more than 
once been sent to smallpox hospitals, with disas- 
trous conseq'uences. Never, in measles, is there so 
severe a pain in the back as in smallpox, while the 
early cough and coryza are only found in measles. 
The lesson taught is to defer a positive diagno- 
sis because less serious mischief may result from 
an error thus occasioned than as the result of an 
opposite course. The possibility of mistaking re- 
lapsing fever for smallpox has been alluded to in 
considering the former disease. Cerebrospinal 
fever may also be simulated by the hemorrbagic 
form of smallpox. Pustular syphilids and acci- 
dental croton-oil eruption have been mistaken for 
smallpox, as has also chicken-pox. 
Prognosis depends upon whether or not the per- 
son has been vaccinated, upon the character of the 
epidemic, and upon the season of the year. If 
there has been a previous vaccination, the progno- 
sis is always good. Occasionally, there is a type 
of smallpox which is virulent in certain epidemics. 
The summer season is always favorable to small- 
pox, as the room can be kept well ventilated, more 
SMALLPOX SMALLPOX 
comfortable, and there is less danger of complica- 
tions. 
The hemorrhagic type is the most fatal. In 
young children the prognosis is very unfavorable. 
Ominous Symptoms in Smallpox.-Eliot has 
always noticed, in moving a patient to the hospital, 
that those who voluntarily covered their faces and 
heads, without any suggestion to do so, invariably 
died. When the face of a white patient assumes a 
dark leaden hue during the first days, death may be 
predicted almost with certainty. Those patients 
who present great swelling of the face and head in 
the beginning always suffer from severe attacks. 
There is a peculiarity of the walk which is very om- 
inous: the patient lifts the feet high, as if he were 
ascending stairs, and this applies to the early 
eruptive stage. The general mortality is from 15 
to 30 percent. 
Prophylactic Treatment.-The patient should be 
isolated. If in the summer, a tent answers very 
well; or a house should be chosen that can subse- 
quently be thoroughly disinfected. Nothing should 
remain in the room that cannot be boiled and 
washed in a solution of mercuric chlorid, 1 : 2000. 
The bed-clothes and bedding should be burned. 
The furniture, walls, and ceiling should be thor- 
oughly scrubbed with soap and water; then with 
the solution of mercuric chlorid, 1:2000; and all 
furniture that can be moved should be sunned for 
at least a week. All sweepings, cloths, and waste 
around the yard should be swept up and burned. 
Burning sulphur and scattering a few drops of 
carbolic acid about an infected place is a primitive 
custom, and does no good unless the cause of the 
evil is removed. Formalin is a good disinfectant. 
See Disinfection. 
The physican should wear such outside gar- 
ments as can be thoroughly washed, and should 
always change the clothing before attending other 
cases. His clothing should be kept in an un- 
occupied room from which all drapery has been 
removed. It should subsequently be disinfected. 
After a visit to a patient with smallpox, the face, 
hair, and hands should be thoroughly scrubbed 
with soap and water; then with a solution of mer- 
curic chlorid-1:1000 on hands and 1:4000 on 
face and hair-taking care that the liquid does not 
come in contact with the eyes. All persons in the 
immediate vicinity of the patient should be vacci- 
nated. See Vaccination. 
Medicinal Treatment.-In mild cases few drugs 
are indicated. In no other disease are careful 
nursing and the proper hygienic precautions more 
necessary. It is always well to begin the treat- 
ment with calomel, 1/4 grain being taken every 
hour until 5 or 6 doses have been taken, followed 
by 1/2 of an ounce of Rochelle or Epsom salt. 
The kidneys should be kept active, and probably 
there is nothing better than potassium bitartrate, 
20 grains of which may be given every 3 or 4 hours. 
Acetanilid or phenacetin may be given for hyper- 
pyrexia. A light nutritious diet should be given. 
If the temperature rises above 102.5° F., it may 
be reduced by the administration of 5 grains 
of phenacetin; or the following formula may be 
given: 
SNEEZING 
1$. Antipyrin, 3 jss 
Tincture of digitalis, 3 ij 
Peppermint water, 3 iij 
Water, enough to make 3 ij. 
One teaspoonful every 3 or 4 hours, if neces- 
sary, to reduce fever. 
These antipyretics, besides reducing the tem- 
perature, mitigate the pain and render the patient 
more comfortable. If the temperature cannot be 
satisfactorily controlled, one should not hesitate to 
use the cold tub-bath. Cool drinks, such as lemon- 
ade, assuage the thirst fairly well. 
As a diuretic: 
I|. Solution of potassium cit- 
rate, gij 
Sweet spirit of niter, 
Elixir of curacoa, 
each, 3 iv 
Water enough to make 3 iv. 
One tablespoonful every 3 or 4 hours. 
If the nervous system begins to suffer, or if the 
heart is weak, 1/2 ounce of whisky may be given 
every 3 or 4 hours. Frequently morphin, 1/4 of a 
grain hypodermically, may be given to relieve pain 
and to produce sleep. 
Finsen's red light treatment has proved effective 
in preventing suppuration. 
Antistreptococcus serum is recommended in the 
stage of pustulation. 
To Prevent Pitting.-Apply cold cream or vase- 
lin on lint to affected parts. Schamberg found the 
most efficient treatment to be painting with iodin. 
Romero advocates picric acid applications (picric 
acid 30 grains, alcohol 1/2 ounce, water 6 1/2 
ounces; or as an ointment). Lint dipped in a 
solution of mercuric chlorid, 1: 3000, may also be 
applied. 
Quarantine should be enforced for at least 2 
weeks. 
SNAKE-BITES.-See Bites and Stings. 
SNAKEROOT.-See Cimicifuga, Senega, 
Serpentaria. 
SNEEZING.-The causes of excessive sneezing 
may be broadly classified as extrinsic and intrinsic. 
Tobacco-snuff and pollen are instances of the 
former, while the latter occur in association with 
various affections, as whooping-cough, asthma, 
hay-fever, gout, hysteria, disordered menstruation, 
derangement of the sexual functions, and preg- 
nancy. A bright fight or an intense color may 
cause excessive sneezing in some persons. The in- 
gestion of pungent substances may cause violent 
sneezing. Some individuals exhibit special idio- 
syncrasy to certain articles of food. For instance, 
in some, chocolate, eaten or drunk, will provoke 
sudden sneezing. The inital sneezing in the be- 
ginning of an ordinary "cold" needs no mention 
here. Impacted cerumen may be a reflex cause. 
Sexual excesses may act similarly. 
Treatment.-An attack may be cut short by 
pressure on some branch of the trigeminal nerve. 
A mustard poultice to the back of the neck, an 
emetic, an astringent nasal inhalation or a spray 
of creosote, iodin, or menthol, or an application to 
the nasal mucosa of a solution of cocain (3 percent) SOAMIN 
SODIUM 
may suffice. The head may be immersed in cold 
water. Irregularity in the function of any af- 
fected organ should be rectified. One drop of 
Fowler's solution 3 times daily may be given in 
paroxysmal sneezing allied to asthma. Potassium 
iodid, 10 grains several times daily, and iodin in- 
halations are sometimes used. In incessant sneez- 
ing, with profuse watery discharge from the eyes 
and nose, camphor powder snuffed and an alcoholic 
solution of camphor inhaled are also recommended. 
See Asthma, Hay-fever. 
SOAMIN.-Sodiumaminophenylarsonate. One 
of the new arsenical compounds used in the treat- 
ment of syphilis. It is almost identical with atoxyl 
though it is claimed to be more stable and hence 
safer; but it is less stable and more toxic than 
arsacetin. Cases of optic atrophy, however, have 
been reported from its use. Dose, 1 to 5 grains. 
See Arylarsonates. 
SOAP (Sapo).-A chemic compound made by 
the union of certain fatty acids with a salifiable 
base. It is used for washing and cleansing pur- 
poses. A table is appended showing the composi- 
tion of the chief soaps of pharmacy, as analyzed by 
M. Dechan. 
Therapeutics.-Soap is a laxative, antacid, and 
antilithic. Externally, it is a stimulating discu- 
tient, and is used for cleansing the skin, removing 
fatty substances, and softening the epidermis; 
but if too long applied, it may prove decidedly 
irritant. It is a good antidote in poisoning by 
acids, and should be administered freely in such 
cases until more energetic alkalies can be obtained. 
In aqueous solution it makes a useful enema for 
constipation, or a plug of soap may be inserted 
into the rectum. Soft soap is a powerful detergent 
stimulant, and is much employed in skin-diseases, 
especially eczema rubrum, in which the tincture is 
well rubbed on, the diseased skin well washed and 
then covered with a bland ointment. The tinc- 
ture is the most desirable form for use, and may 
be diluted with 3 parts of alcohol for shampooing 
the scalp. The liniment is used with friction in 
sprains, bruises, and stiff joints, being a little more 
stimulating than camphor liniment. It makes a 
good basis for extemporaneous liniment prescrip- 
tions. 
Preparations.-Sapo (white castile soap) is soap 
prepared from sodium hydroxid and olive oil; a 
whitish solid, hard, yet easily cut when fresh, of 
faint, peculiar odor free from rancidity, a disagree- 
able alkaline taste and alkaline reaction; readily 
soluble in water and in alcohol. It is an ingre- 
dient of three of the official pills, and two plasters. 
Sapo Mollis, soft soap, green soap, is soap pre- 
pared from potassium hydroxid and linseed oil; a 
soft, unctuous mass, of a yellowish-brown color, 
soluble in about 5 of hot water and in 2 of hot 
alcohol. The name green soap is a misnomer, as 
it is not green in color. Insoluble soaps are com- 
binations of the oily acids with earths and metal 
oxids, as the soap of lime, official as linimentum 
calcis, and the soap of lead monoxid, the former 
lead plaster. Emplastrum Saponis has of soap 10, 
lead plaster 90, water q. s. Linimentum Saponis 
has of soap 6, campor 4 1/2, oil of rosemary 1, 
alcohol 72 1/2, water to 100. Opodeldoc is a 
similar preparation. Soap liniment is an ingre- 
dient of chloroform liniment. Linimentum Saponis 
Mollis, tincture of green soap, has of soft soap 65, 
oil of lavender 2, alcohol to 100. 
Variety. 
Fatty Acids. 
Combined Alkali. 
Free Alkali. 
Silica. 
Sulphates and 
Chlorides. 
Insoluble Mat- 
ter. 
Water. 
Insoluble in 
Alcohol. 
Hard soap (sapo 
durus). 
81.5 
9.92 
0.08 
0.28 
0.20 
10.65 
0.50 
White Castile 
soap (sapo Cast, 
alb.). 
76.7 
9.14 
0.09 
.... 
0.36 
0.90 
13.25 
0.60 
Mottled Castile 
soap. 
68.1 
8.9 
0.19 
0.15 
0.63 
0.80 
21.70 
1.30 
Tallow soap (sapo 
animalis). 
78.3 
9.57 
0.28 
0.47 
0.40 
12.50 
1.10 
Soft soap (sapo 
mollis). 
48.5 
12.6 
0.380.17 
0.93 
1.00 
39.50 
1.60 
SOAPBARK.-See Quillaja. 
SODA-WATER.-See Carbon Dioxid. 
SODIUM.-Na = 23; quantivalence, 1; sp. gr., 
0.972. A metal of the alkaline group, character- 
ized by its strong affinity for oxygen. It has a 
silver-white luster, and is softer than lead. It 
decomposes water, forming sodium hydroxid. 
The action of the sodium salts is similar to that 
of the potassium salts, except that the former are 
feebler as alkalies, are not so depressant, and are 
not so poisonous to the cardiac muscle or the 
nerves. They are diffused more slowly, are 
neither absorbed nor excreted so readily, and 
have not so marked diuretic action. Locally 
applied in large doses to muscular and nervous 
tissues they are paralyzant, but not so powerfully 
as potassium salts. Sodium urate is not soluble 
like the urates of lithium and potassium, and is 
therefore much less readily excreted, forming 
the masses called chalk-stones in gouty subjects. 
Soda is a less active escharotic than potash, having 
less affinity for water. Liquor sodii hydroxidi renders 
the blood and secretions more alkaline, but does 
not alter nutrition to the extent that the potassium 
solution does. The acetate is converted into the 
carbonate in the blood, and is a less active diuretic 
than the corresponding potassium salt. The car- 
bonate is irritant to the stomach, and is chiefly 
used in the preparation of the other salts. The 
nitrate is mildly purgative and diuretic, and in solu- 
tion is solvent to false membranes. The ethylate 
is antiseptic, and a powerful but almost painless 
escharotic. Sodium bicarbonate has the same 
action as the corresponding potassium salt, ex- 
cept that it is more slowly absorbed and is less 
depressant. It is antacid, antipruritic, and anal- 
gesic, the latter being probably due to the increased 
alkalinity imparted by it to the blood. Internally 
in small doses it is neutralized by the hydrochloric SOFTENING OF THE BRAIN 
SOMNAMBULISM 
acid of the gastric juice; in medium doses it is 
solvent to the gastric mucus, slightly irritant to 
the stomach, and sedative to the gastric nerves; 
in large does it renders the stomach contents neu- 
tral or alkaline and stops the gastric digestion. 
Preparations.-S. Acetas, NaC2H3O2. 3H2O, 
diuretic, a good saline draft. Dose, 5 to 30 grains. 
S. Arsenas, Na2HAsO4, used in preparing liquor 
sodii arsenatis. S. Benzoas, NaC7HsO2. Dose, 
10 to 30 grains. S. Bicarbonas, HNaCO3, "salera- 
tus," "baking soda"; antacid; 20 grains neutralize 
16.7 grains of citric acid or 17.8 grains of tartaric 
acid. Effervescent. It is much used for the 
aeration of bread. Dose, 10 to 30 grains. S. 
Bicarb., Troch., each contains 3 grains of the salt. 
S. Boras, Na2B2O7, borax (q. v.) S. Bromidum, 
NaBr. Dose, 10 to 30 grains. S. Cacodylate. See 
Cacodylic acid. S. Carbonas, monohydratus, 
Na2CO3, antacid; 20 grains neutralize 9.7 grains of 
citric or 10.5 grains of tartaric acid. Effervescent. 
Dose, 1 to 7 grains. S. Chloras NaC103, the basis of 
an agreeable gargle. Dose, 1 to 10 grains. S. 
Chloridum, NaCl, common salt. Dose, 10 grains 
to 1 dram. S. Cinnamas. See Cinnamic Acid. 
S. Citras. Dose, 5 to 30 grains. S. Ethylas, 
C2H5NaO, caustic alcohol, unof., in contact 
with water breaks into caustic soda and alco- 
hol. Sodium Glycocholate, an excellent chola- 
gogue, markedly stimulating the digestion of fats. 
Its dose is 2 to 5 grains. S. Hydroxid, Na(HO), 
"caustic soda," very alkaline and powerfully 
escharotic. S. Hydroxid. Liq., solution of soda. 
Dose, 5 minims to 1/2 of a dram well diluted with 
water, contains 56 parts of the hydroxid in 944 of 
distilled water. S. Hypophosphis, NaPH2O2 used 
in preparing syrupus hypophosphitum. S. lodi- 
dum, Nai. Dose, 3 to 10 grains. S. Nitras, 
NaNO3, "cubic niter," "Chili saltpeter." Dose, 5 
to 30 grains. S. Nitris, NaN02, used in preparing 
sweet spirit of niter. S. Oleas. Antacid and mild 
laxative. Dose, 2 to 20 grains. S. Perboras. Anti- 
septic and bactericide. A substitute for hydrogen 
peroxid. S. Phenolsulphonas, NaC8H5SO42H2O2, 
(sodium sulphocarbolate). Dose, 10 to 15 grains. 
S. Phosphas, Na2HPO4, sodium orthophosphate. S. 
Pyrophosphas, Na2P2O7, sodium pyrophosphate. 
S. Salicylas, NaC7HsO3, sodium salicylate. Dose, 
10 to 15 grains. S. Santonas, Na2C15HlgO4, a ver. 
mifuge for thread-worms. Dose, 5 grains. S- 
Sulphas, Na2SO4, "Glauber's salt," a mild purga- 
tive. Dose, 5 to 20 grains; as a purgative, | to 1 
ounce. S. Sulphis, Na2SO3, sodium sulphite. S. 
Thiosulphas, Na2S2O3 + 5H2O, an antiseptic salt. 
SOFTENING OF THE BRAIN.-A disease of the 
cerebral tissue dependent upon inflammation or 
blood failure, the symptoms varying according to 
the part affected, but consisting of loss of function, 
partial or complete. According to the appearances 
presenting, the softening has been distinguished as 
red, yellow, or white. See Paralysis (General). 
SOLUTION.-See Liquor; Percentage Solu- 
tions. 
SOMATOSE.-A preparation in which the albu- 
minoids and nutritive constituents of flesh are 
converted into soluble albumoses, 5 parts of soma- 
tose representing 30 parts of beef in nutritive value. 
It forms a pale yellowish powder, which is readily 
soluble in water, forming an almost odorless and 
tasteless solution. It is employed as a food for 
patients afflicted with weak digestion, 1/2 to 1 
ounce being given in milk, cocoa, or soup. 
Iron Somatose (Ferrosomatose).-A prepara- 
tion of somatose containing about 2 percent of iron 
in organic composition, and forming a light brown, 
inodorous, and tasteless powder, readily soluble in 
warm fluids; it does not attack the teeth or con- 
stipate. Dose, 1 to 3 drams daily. 
Milk Somatose.-A tasteless, inodorous, strength- 
giving food-product in powder form, prepared 
from milk. It contains the albumoses of milk in 
soluble form with 5 percent of tannic acid organic- 
ally combined. It is used in chronic diseases of 
digestive organs such as are connected with in- 
flammation of the stomach and with typhoid con- 
ditions. Daily doses for children, 1 or 2 teaspoon- 
fuls; adults, 2 or 3 tablespoonfuls. 
SOMNAL.-A hypnotic formed by the union of 
chloral, alcohol, and urethane. It acts like chlo- 
ral, but is more pleasant. It occurs as a colorless 
liquid, resembling chloroform in its behavior with 
cold water, forming globules and refusing to dis- 
solve or mix. It is soluble in hot water, in 
alcohol, and in alcoholic solutions 3:1. The 
advantages claimed for it are that in 20-grain 
doses it induces a quiet sleep, within a half- 
hour, lasting for 6 to 8 hours, and with no un- 
pleasant after-effects. Doses of 45 or even of 
60 grains do not depress the heart. Doses of 
30 grains in solution with syrup of tolu or whisky 
are well borne and without deleterious effects. 
Its effects are more striking than urethane and less 
depressing than chloral. There is no vertigo, as 
after sulphonal. It is not powerful enough to con- 
trol delirium tremens, maniacal delirium, or severe 
pain, but manifests its best hypnotic and sedative 
action in insomnia of convalescence from acute 
disease. In whooping-cough, in spasmodic laryn- 
gitis and in asthma, in the so-called "nervous 
cough," in chorea, in melancholia, and in mental 
depression, it is of much use. It is said to be in- 
jurious in general paralysis, and to be contraindi- 
cated in cases of impaired digestion. 
SOMNAMBULISM.-The condition of half sleep, 
in which the senses are but partially suspended; also 
termed sleep-walking. Also the type of hypnotic 
sleep in which the subject is possessed of all his 
senses, often having the appearance of one awake, 
but whose will and consciousness are under the 
control of the operator. Charcot calls this simply 
somnambulism, which constitutes the third type of 
the hypnotic state. The second he calls catalepsy, 
produced by the gong suddenly sounded or the 
electric light suddenly brought before the subject's 
eyes; the eyes are wide open, and the muscles 
acquire the curious waxy condition designated 
as flexibilitas cerea. The subject seems to have 
no mental communication with the outside world. 
This latter characteristic also distinguishes lethargy, 
or the first type of the hypnotic state, in which 
there aro unconsciousness, irresponsiveness of the 
senses to stimulation, and a fixed positon of certain 
muscles. See Catlepsy, Hypnotism. SOMNIFACIENTS 
SPECTACLES AND EYE-GLASSES 
Somnambulism is pratically confined to child- 
hood and youth. Idiots and imbeciles are rarely 
affected. There may be no definite symptoms of 
ill health in the simpler cases. A neurotic tempera- 
ment or a tendency to disturbances of the nervous 
equilibrium, such as epilepsy, hysteria, chorea, or 
migraine may exist. Other cases may be accom- 
panied by mere chargin, anger, or surprise. 
The eyelids are uually closed, but may be open, 
and the pupil is dilated. The sense of touch is 
much exalted, and a sleep-walker seldom runs 
against furniture, chairs, etc. Some subjects hear 
well, others do not. The sense of smell varies with 
the subject. A sleep-walker may enjoy a meal 
and not remember the fact of having eaten. 
Sensibility to pain may be entirely suspended. 
The muscular system is intact, and permits of 
extraordinary exploits. The ordinary mental proc- 
esses are active in somnambulists, and elaborate 
work may be performed. A dream in all proba- 
bility precedes and accompanies the action taken. 
Occasionally, the particular dream may be recalled. 
Vivid hallucinations may arise, determining the 
particular act to be performed. Speaking and 
singing are not uncommon. 
Treatment.-Treatment is limited to regulating 
any indiscretions in diet and correcting any gastric 
disturbance. The best hygienic surroundings for 
quiet sleep should be obtained. See Insomnia. 
SOMNIFACIENTS.-See Hypnotics. 
SOMNOFORM.-A mixture of ethyl chorid 60, 
methyl chlorid 35, ethyl bromid 5, said to be more 
rapid in action than ethyl chlorid. 
SORBEFACIENTS. (Discutients).-Agents pro- 
moting absorption. They may be divided into 
two classes: (1) those which stimulate the lymph- 
atics to the removal of morbid or inflammatory 
deposits, (2) those which promote the imbibition 
of nutritive or medicinal material into the system. 
(See Alteratives.) These agents include the fol- 
lowing: arsenic, mercury, iodin, iodids, cadmium, 
ichthyol, lanolin, oleic acid, cacao butter, massage, 
vapor bath, hot water bath, poultices, counter- 
irritation, galvanism. 
SORE THROAT.-See Laryngitis, Pharyngi- 
tis, Tonsillitis. 
SPANISH FLY.-See Cantharis. 
SPARTEIN.-A volatile liquid alkaloid not con- 
taining oxygen. It occurs in Scoparius, and is a 
colorless, thick oil, boiling at 311° C. It is narcotic. 
It stimulates the action of the vagus, and acts 
more quickly than digitalis, but not so powerfully. 
It is an uncertain diuretic and cardiac tonic, but 
is often efficacious when digitalis fails. Dose, 
of the sulphate, 1/5 grain. See Scoparius. 
SPASMS, INFANTILE.-See Convulsions (In- 
fantile). 
SPEARMINT.-See Mentha Viridis. 
SPECIFIC GRAVITY.-The comparative weight 
of bodies of equal bulk. It is ascertained by 
weighing the bodies with an equal bulk of pure 
water at a given temperature and atmospheric 
pressure, which is taken as the unit. 
To obtain the specific gravity of a body, it is 
only necessary to balance it with an equal bulk of 
the standard and to ascertain how many times the 
weight of the standard is contained in its weight. 
For example, a fluidounce of water (standard) 
weighs 455.7 grains; a fluidounce of lime-water 
weighs 456.3 grains; 456.34-455.7 = 1.0015: that is, 
the lime-water weighs 1.0015 times more than 
water, bulk for bulk. In other words, its specific 
gravity is 1.0015. A fluidounce of alcohol weighs 
422.8 grains; 422.84-455.7 = 0.928, specific gravity. 
This general rule may be given for finding 
specific gravity: Divide the weight of the body 
by the weight of an equal bulk of water; the 
quotient will be the specific gravity. 
SPECIFICS.-Agents which have each a selec- 
tive curative influence on a particular disease. 
Mercury is said to be specific to syphilis, quinin to 
malaria, and other drugs are more or less specific to 
certain affections, but they have so many actions 
and uses that they are usually placed in other 
groups. The true specifics are the various animal 
extracts and sera, though even these are being 
found remedial in other than their specific dis- 
eases. The most important of these agents are the 
thyroid and suprarenal glands, and antidiphtheritic 
serum or diphtheria antitoxin, which are official 
but many other animal extracts and sera are used 
in medicine. , 
SPECTACLES AND EYE-GLASSES.-The fit- 
ting of spectacles and eye-glasses is a most neces- 
sary adjunct to the art of ophthalmology. Spec- 
tacles should always have stout temple-pieces, to 
maintain their shape and stay in proper position 
by their weight. To prevent jarring while walking 
or running, the sidepieces should fit closely to the 
face and temples; in fact, it is sometimes preferable 
that they should exert sufficient pressure to slight- 
ly groove the skin. By this means a definite and 
fixed support is given. Fourteen-karat gold is to 
be preferred, and stout steel should be the second 
preference. Although silver does not rust, it can- 
not be made of sufficient rigidity. Delicate wires, 
either of gold or steel, should not be accepted, as 
they can only maintain their position by uncom- 
fortable pressure behind the ears and on the nose. 
Spectacles are preferable to eye-glasses when- 
ever there is astigmatism, or when the nose is not 
properly shaped for the ready adjustment of eye- 
glasses. Hooks are to be preferred to straight 
temple-pieces when the glasses are to be worn con- 
stantly. Reading-glasses are sometimes more 
convenient with straight side-pieces, particularly in 
women, on account of the abundance of hair about 
the temples. For constant use, lenses should be 
slightly inclined at a compromise angle between 
the straight position and the inclination preferred 
for a reading-glass. Of course, the occupation of 
the patient must be taken into consideration in 
adjusting the glass. In high defects the glasses 
should be fitted closely to the eyes, and, if neces- 
sary, the lashes should be trimmed from time to 
time. Glasses should be worn constantly in high 
defects, in astigmatism, and in all cases in which 
there are asthenopic or reflex symptoms. 
Bifocal glasses are particularly valuable for a 
presbyope or for a myope of high degree who is 
compelled to use different glasses for reading and 
for distance. The improved form, with a reduced SPECTACLES AND EYE-GLASSES 
curved segment cemented on the distance glass, is 
far more satisfactory than the old straight 
Franklin bifocals. The lower segment should be 
about 2 cm. wide, and the upper edge should be 
more curved than the lower. If the occupation of 
the patient subjects him to high degrees of heat or 
steam, the lower segment should be inserted into 
a groove in the bottom of the distance glass in- 
stead of being cemented on. Although it takes 
the patients some little time to become accus- 
tomed to bifocal glasses, they ultimately give far 
greater satisfaction, and are more convenient 
than two different pairs of glasses. 
SPEECH-DEFECTS 
Tinted glasses of any kind should never be or- 
dered for constant use, but only temporarily pre- 
scribed in inflammatory conditions, during mydri- 
asis, for use at the seashore, etc. Once formed, the 
habit of wearing tinted glasses is difficult to over- 
come. Photophobia is usually due to uncorrected 
or improperly corrected ametropia. It is a well- 
known fact that tinted glasses are most used in 
countries in which the importance of eye-strain in 
comparatively low defects is unrecognized. Dur- 
ing mydriasis, London smoked piano-lenses 
should be worn. Coquilles generally have some 
spheric or cylindric effect on an irregular surface. 
See Lenses. 
The Care of Spectacles.-" Spectacle frames will 
last longer and perform their function better if the 
wearer is instructed to exercise care in handling 
them. In putting them on and off, the hooks 
should be lifted from or into their position behind 
the ears; both hands being used, so as to avoid 
straining the temples widely apart or otherwise 
bending them. They should be folded together as 
little as possible, and when not in use should be laid 
in a safe place, open, and resting on the edge of the 
lenses, to avoid scratching the surfaces of the latter. 
For cleansing them nothing is better than a piece of 
clean old linen, or, if very much soiled, a little 
ammonia and water may be used, except on ce- 
mented bifocal glasses. While cleansing, the 
frame should be grasped by the end piece and not 
by the bridge, and in replacing the glasses on the 
eyes care should be taken not to crush them against 
the lashes and thus soil the refracting surfaces at 
once. When cylindrical or prismatic glasses are 
Bifocal Lens. 
B. Distance lens. A. Reading lens, cemented to the 
Distance lens. 
"In another form of bifocal glass the small sup- 
plemental lens is countersunk, that is to say, is 
cemented into a corresponding concavity ground in 
the distance glass. Or the distance glass may be 
composed of two full-sized plano-convex lenses 
with their plane surfaces in apposition, each of 
these surfaces being ground out at its lower part, so 
as to house the small supplemental lens between 
them. These two forms admit of a reduction of 
weight and the abolition of chromatic aberration in 
the heavy glasses required in aphakia. To accom- 
plish the latter purpose the distance lens is made of 
crown glass and the supplemental lens of flint glass. 
In this form they are called achromatic bifocals. 
Their disadvantage lies in the expense of their manu- 
facture. 
"Fused bifocals are a variant of the countersunk 
supplemental lens. In their manufacture a small 
lens of flint glass is let into a large lens of crown 
glass by countersinking. Instead of cementing the 
supplemental lens in position, however, the lenses 
are heated to the point of fusion of the glass, when 
its two portions unite. The surfaces of the glass 
are then reground. One surface of the small sup- 
plemental lens is exposed to the grinding and is 
reduced to the same curvature as the correspond- 
ing surface of the main lens. The necessary differ- 
ence in the refraction of the upper and lower por- 
tions is dependent on the difference in index of 
refraction of the crown glass of which the main 
lens is composed and the flint glass of the sup- 
plemental lens" (Phillips). 
Before discharging the patient, the adjustment 
of the glasses should be carefully examined and 
the correctness of the lenses verified by neutraliza- 
tion. The good effects of many a careful diagnosis 
of refraction are ruined by maladjusted and decen- 
tered glasses. 
worn, patients may return after a time with the 
statement that the spectacles are unsatisfactory, 
when the trouble will frequently be found to be due 
to bending of the frame; or a lens may have fallen 
out and been replaced upside down, or with the 
wrong edge inward. It is well to have such per- 
sons report periodically to have their glasses re- 
adjusted" (Phillips). 
SPEECH-DEFECTS.-The importance of speech 
as a factor2 in the mental and physical growth of 
our race is not generally appreciated. Speech 
has been defined as "a system of articulate words 
adopted by convention to represent outwardly 
the internal process of thinking"; but not only 
does it represent the process of thinking, but it is 
Fobms of Bifocal Lenses.-{Phillips.) SPEECH-DEFECTS 
SPEECH-DEFECTS 
so closely interwoven with it as to be essential to 
its highest development. Speech is also one of the 
essentials to the highest physical development, for 
its use tends to expand the chest and aerate the 
blood. The faculty of speech is presided over by 
delicate and complicated cerebral areas inciting 
to action and working in harmony with peripheral 
organs having other important bodily functions in 
addition to those of voice and speech production. 
Defective speech, therefore, having its origin in a 
defective action of some of these important cen- 
tral areas and peripheral organs, is a serious malady, 
and deserves most careful consideration. 
For convenience of study, these defects may be 
divided into two classes: in the first class are all 
those cases in which the defect is the chief cause for 
complaint; and in the second, those in which it is 
merely a symptom of some more alarming condi- 
tion: as, for example, cerebral abscess or intra- 
cranial pressure, from whatever source. 
It is convenient, also, to make two divisions of 
this class; and of the terms that have been used to 
designate them, the best are dyslalia and pseudo- 
lalia. Under dyslalia come those forms of defec- 
tive speech in which there is difficulty of utterance: 
as, for example, stammering, or stuttering; and 
under pseudolalia come all those defects that may 
be characterized as slight deviations from the nor- 
mal speech, as the slurring or omitting of certain 
elements and the substitution of one element for 
another. 
immense and is out of all proportion to that which 
is required. So in the normal person speech tends 
to become automatic and to require the least possi- 
ble amount of nervous energy; but when something 
happens to interfere with the development of this 
automatic action of the organs of speech, and vol- 
untary action attempts to come to the rescue, the 
result is always more or less of a failure. There is 
a surplus of nervous energy expended, and this 
surplus overflows, so to speak, into muscles that 
may have but little to do with the process of 
speech production-and the result is a spastic con- 
traction, or a spasm of these muscles. 
The overflow takes place along the channels of 
least resistance, which channels vary in different 
individuals; and, therefore, the spasm does not 
occur in the same muscles in all cases, nor, indeed, 
in any two cases. It may occur in almost any 
part of the muscular system, and its manifesta- 
tion is often grotesque in the extreme. 
Etiology.-The cause of stammering has given 
rise to much conjecture, and many superficial 
observers have supposed that they had discovered 
it, only to be disappointed upon further investiga- 
tion. The mistake has been made of supposing 
that there is but one cause for stammering, and 
that this cause operates alike in all cases. The 
fact is, there are many causes, as there are many 
causes for dyspepsia or any other functional dis- 
turbance; and the precise cause in any individual 
can only be determined after a careful and often- 
times prolonged study of the case. 
Among the predisposing causes heredity must be 
placed first. About 35 percent of the reported 
cases had relatives who stammered. It is an af- 
fliction that belongs to youth, and it begins at, or 
soon after, the time the child begins to talk. It 
may continue to old age; but stammerers, as a rule, 
are not long lived. Statistics show that about 84 
percent of all cases seeking relief are males, and 
this would seem to indicate that sex must be 
regarded as a factor in the cause of the affection. 
A nervous temperament, either inherited or 
acquired, is a condition common to most children 
who stammer. This condition may follow one of 
the infectious fevers or other diseases of childhood, 
or it may be the result of eye-strain, hypertrophied 
tonsils, adenoid vegetations, or intranasal pressure 
from whatever source. About 15 percent date 
the origin of their trouble to a severe nervous shock 
caused by fright or injury. One child had his head 
ducked in a tub of cold water and has stammered 
ever since. Another was threatened with arrest by 
a policemon for playing "pussy" on the street. He 
was thrown into a convulsion, and has stammered 
from that time. A child fell downstairs and 
received a slight injury, attended by a great nerv- 
ous shock, and stammering immediately followed. 
The various neuroses are more or less prevalent 
in stammerers and in their ancestors, and therefore 
they must be regarded as probable predisposing 
causes. Not only do glandular enlargements in 
the pharynx and intranasal hypertrophies and 
spurs act as causal factors in this affection, indi- 
rectly and in a reflex manner through the nervous 
system, but in so far as they interfere directly with 
Stammering (Dyslalia). 
Stammering may be defined as interrupted 
speech characterized by a spasm of certain 
opposing muscles more or less closely related to 
the vocal or oral articulating mechanism. This 
spasm is not always confined to the muscles directly 
concerned with speech, but may extend to any 
part of the body, especially when great effort is 
made to overcome the interruption. It is never 
exactly the same in any two cases, nor does it 
always remain constant either in degree or loca- 
tion, but it changes with the temperament of the 
individual. The phlegmatic person will some- 
times stand and only stare, and use no apparent 
muscular effort at all until such time as he thinks 
he may be able to proceed. This has been called 
the silent form of stammering, and in it there is 
but little noticeable spasm. In the majority of 
cases, however, the tendency is at least to try to 
speak, and the degree and extent of spastic muscu- 
lar contraction will be proportionate to the 
strength of the effort put forth. 
A muscular spasm, therefore, of greater or less 
intensity is the one condition that is characteris- 
tic of all forms of stammering. The cause of this 
spasm is manifestly a result of misapplied energy 
in the effort to speak, and it has its counterpart in 
the grimaces of the letter-writer unaccustomed to 
the occupation, and in the muscular contortions 
of the beginner on a bicycle. To the expert, the 
control of a pen or a bicycle becomes automatic, 
and the nervous energy expended is almost nil; 
but to the beginner, the control must be voluntary, 
and the amount of nervous energy expended is SPEECH-DEFECTS 
the free automatic action of the muscles of vocal- 
ization and articulation must they be considered 
as direct causes. Moreover, we find decided evi- 
dences of arrested or imperfect development in the 
articulating organs of a large percentage of these 
cases. High and irregular palatal arches are more 
common than in persons having normal speech; 
bifid uvula is of frequent occurrence, and we 
often find abnormalities in the various muscles of 
the tongue. A very large and imperfectly shaped 
epiglottis may prove to be the cause in some cases. 
Anything that interferes with the uniform develop- 
ment and harmonious action of the various 
mechanisms of speech must be placed among the 
causal factors of this affection. 
Treatment.-Few children would be confirmed 
stammerers if they could have the proper treat- 
ment at the very inception of the trouble. What- 
ever may be the direct or exciting cause in any 
particular case, the child begins to hesitate in 
speech during a period of mental excitement. 
There is a confusion of ideas that leads naturally to 
a confusion of words and of the elements of which 
words are composed. It is here that the turning- 
point is made. Usually, the child is scolded or 
ridiculed, either of which procedures tends to add 
to the confusion and to make future attempts at 
oral expression still more difficult. 
If the little patient can be tided over this period 
of nervous excitement, in most cases the develop- 
ment of the affection is prevented. Most careful 
and gentle treatment should be employed. Any 
attempt at speech should be interdicted until 
mental quietude is fully established. A careful 
examination should now be made, with a view to 
discovering the cause of the trouble, bearing in 
mind that any condition that may add to the 
nervous excitability of the patient becomes a 
contributory cause. Especially must the nose, 
the nasopharynx, and the throat be examined for 
obstructions. Careful examination of the mouth 
should also be made, and so far as possible any 
irregularities of structure should be corrected and 
glandular enlargements reduced; the general 
health of the patient should be put in the best 
possible condition. 
During all this time the child should be encour- 
aged to talk but little, and to think of only one 
thing at a time, and to express his thoughts with the 
greatest deliberation. The word "stammering" 
should never be used in his hearing, nor should his 
attention be directed in the slightest possible de- 
gree toward his speech; for the fear of future 
trouble in speech is easily aroused, and it is one of 
the greatest obstacles in all cases to the accom- 
plishment of a cure. 
The automatic action of the various mechanisms 
of speech is no longer possible and the patient is 
equally incapable of voluntary control of these 
mechanisms. Manifestly, the object to be at- 
tained is the reestablishment of the normal auto- 
matic processes of speech, and this can only be 
done, in a great majority of cases, by making use of 
voluntary control of the vocalizing and articulating 
muscles, and thus gradually, but unconsciously, 
leading the patient back to the normal proc- 
SPEECH-DEFECTS 
esses of speech. The first step should be to try to 
discover the cause, and to remove it if possible. 
It is well to remember, however, that the original 
cause may have long since ceased to exist, and that 
only the results may remain. The stammering, 
for instance, may be the result of a nervous shock 
received years ago, or of an adenoid growth long 
since removed; so that the exciting cause of the 
trouble may not be apparent at the time of the 
examination. If, however, we can find any condi- 
tion that may impair the harmonious action of the 
nervous system, our attention should be directed 
toward its improvement. 
The general health of the patient, his diet and 
methods of life, should be carefully investigated and 
regulated in the minutest detail. The organs of 
articulation and vocalization should be carefully 
examined, and an attempt made to correct any 
abnormality, however slight it may be. A short 
lingual frenum interfering with the normal action of 
the tongue is often a great hindrance to freedom of 
speech, and we frequently find an abnormal develop- 
ment in the various muscles of the tongue; and 
whether it is the cause or the result of stammering, 
a slight surgical operation, followed by carefully 
chosen exercises, will assist very materially toward 
accomplishing the desired result. Irregularities in 
the structure of the palate are common in these 
cases. There is great lack of uniformity in the 
size and shape of the palatal half-arches. This is 
probably due in a great measure to adhesions that 
form between the folds of the palate and the ton- 
sil, thus causing these folds to be irregularly bound 
down to the tonsil and interfering with their normal 
action in speech. The condition is easily corrected 
by the separation of the adhesions and a slight 
cauterization of the cut surfaces of the tonsil, to 
prevent the formation of new adhesions. The 
vault of the pharynx must be examined, and catar- 
rhal conditions treated on general surgical and 
therapeutic principles. Nasal stenosis, while it 
may not be a common cause for stammering, 
undoubtedly serves as an obstruction to its cure, 
both by its interference with normal respiration 
and its reflex influence on the nervous system. 
Intranasal pressure, therefore, should be removed 
by surgical procedures, if necessary. 
Having corrected the patient's habits of life, both 
dietary and moral, and having removed, so far as 
possible, all other sources of nervous excitability 
and physical and mental depression; and having 
put the peripheral organs of speech in the most 
favorable condition for normal action, the after- 
treatment should consist in the development of a 
perfect voluntary control of certain important 
muscles employed in respiration, vocalization, and 
articulation; and this, as has been suggested, 
should be used as a means-and in the majority of 
cases it is the only means-for the reestablishment 
of the normal automatic muscular action. 
Unfortunately, many stammerers are deficient in 
will power, and in these cases a voluntary control is 
difficult to acquire. They not only do not control 
their speech, but, to use an expression that is com- 
mon among them, they " stammer in other things" 
as well. They do not think connectedly nor do SPEECH-DEFECTS 
SPEECH-DEFECTS 
they pursue any line of action to its logical con- 
clusion. These are the cases that are difficult to 
cure, although they are by no means hopeless. The 
faculty of the will may be developed by training, 
just as any other faculty of the mind may be devel- 
oped; and there are no exercises so efficient for 
this purpose as those required for the improve- 
ment and development of speech. 
To gain voluntary control over the organs of 
speech, certain important muscles that have been 
considered hitherto as involuntary must be brought 
under the domination of the will. These muscles 
belong for the most part to the vocal and respir- 
atory mechanisms. The management of the 
breath, which is the motor power of the vocal 
mechanism, is deficient in all cases of stammering, 
and it is to this point that attention should first be 
directed. 
There is a certain definite and precise action of 
the great muscles about the lower thoracic and 
abdominal regions that is necessary to the produc- 
tion and control of voice, and that must be acquired 
by the patient before any real progress can be 
made or permanent improvement can take place. 
Just what the precise action of each one of these 
muscles is has been the subject of much discussion, 
and its importance in connection with this work can- 
not be overestimated. This action is exceedingly 
complicated, and cannot well be explained within 
the limits of this article and without a subject for 
demonstration. 
The respiratory muscles must be so used as to 
bring just sufficient breath upon the vocal cords, 
and no more than is sufficient, to produce the 
syllable or word that is required. Not only so, 
but this little blast of breath must come at ex- 
actly the proper instant for the production of the 
sound. A lack of promptitude at this point is ob- 
served in many cases. The voice, of which speech 
is made, is not present or forthcoming at the instant 
that the oral mechanism requires it for articulation. 
The articulating organs try to perform their func- 
tion, but there is no voice present to be articulated, 
and the result is a more or less spasmodic hesitancy. 
The patient dwells upon the initial consonant or 
repeats it until such time as the vocal mechanism 
may come to the rescue with the vocal element that 
is necessary for the' completion of the syllable or 
word. 
In other cases it is the oral mechanism that is at 
fault, and the patient dwells upon the vocal ele- 
ment or repeats it until such time as the articulat- 
ing organs may be brought into action for the for- 
mation of the syllable or word. Suitable exer- 
cises must be given to make the action of these two 
mechanisms entirely harmonious, and this can be 
done by teaching the voluntary control of the 
various muscles of that mechanism in which the 
action is delayed, and then practising this volun- 
tary control daily until the necessary promptitude 
of action is acquired. 
In most cases it is necessary, for the exercise of 
this voluntary control, to have the patient speak 
in syllables. Alexander Graham Bell has said that 
syllabification is the cure for all vocal and oratoric 
defects. Of course, this is claiming too much for 
the exercise, but it certainly should have a promi- 
nent place in the treatment of stammering. In 
many cases it is necessary even to divide the 
syllables into their component parts and to drill 
the patient on these individual elements. Then, 
after a certain time, the elements that unite to form 
each syllable should be practised together and 
syllabic conversational exercises given, with care- 
ful attention to voluntary control over the impor- 
tant respiratory and vocalizing muscles. 
In all these exercises there should be an attempt 
to harmonize the various faculties of the mind, not 
only with one another but with the exercises them- 
selves. The patient should be induced to think 
introspectively and to study the impressions that 
the proper muscular action in the production of 
each syllable makes upon the mental and physical 
organisms. Not only should he be conscious 
through his sense of hearing that the syllable is 
accurately given, but he should be taught to 
recognize, by means of the sense of feeling, the 
physical impressions made by the normal action of 
the muscles and the resultant vocalization. 
The stammerer generally knows how the syllable 
would sound if properly given, but he has no defi- 
nite knowledge of how it would feel to give it or 
what would be the physical and mental impressions. 
In other words, the mental and physical sensations 
of speech should be studied and developed in what 
has been called the kinesthetic center of the brain; 
and after these sensations are recognized and felt, 
the patient should be taught to reproduce them. 
In this division may be conveniently placed all 
those defects of speech in which there is no spas- 
modic hesitation. The chief characteristic of this 
form would be a defective or false utterance of cer- 
tain syllables or words. In some cases there is a 
substitution of one element for another. In others 
there may be an entire omission of the element. 
In one case that has been reported there was a 
complete substitution of a language entirely 
unknown for that which the patient attempted to 
use; and not a single element of this false language 
had any resemblance to the element for which it 
was substituted. 
This, however, is unusual, and the majority of 
these cases give proper utterance to at least one of 
the elements and thus suggest the syllable or word 
intended to be spoken. The first element in a 
word is sometimes omitted, and, as some one has 
said, the word becomes "decapitated." More 
often, however, the final consonant is not given, 
and the word becomes " decaudated"; and when 
all the elements are mispronounced, the word may 
be said to be " mutilated." This mutilated speech 
is characteristic of imbeciles and idiots and all 
those having a cerebral lesion. That there is some 
defective cerebration in all these cases must be 
admitted. 
Nice distinctions are not made in the utterance 
of the various elements of which words are com- 
posed. The auditory word center in the brain 
fails to recognize or to register accurately the exact 
sound produced by the peripheral organs of speech. 
Pseudolalia. SPEECH-DEFECTS 
SPEECH-DEFECTS 
No distinction may be made, for instance, in the 
physiologic sounds of the consonants D and G or 
T and K; the one being substituted for the other 
without any conscious recognition of the substitu- 
tion, or one of these consonants may be omitted 
entirely and the ear fails to recognize the omission. 
Other cerebral areas may be similarly deficient 
in the performance of their natural functions, or, 
as is often the case, this auditory center is the only 
one affected. It must be remembered also that 
normal cerebral development depends very 
largely upon the use of the faculty of speech, and 
therefore that defective mentality which at first 
glance may seem to be the cause, may in reality 
be the result, of defective speech. 
Pseudolalia, like dyslalia, often has its origin in 
abnormalities in the structure of the peripheral 
organs of speech. The slightest irregularity in the 
organs of articulation may be responsible for the 
development of mutilated speech ih children. It 
may be said that anything that interferes with the 
normal action of the articulating organs may 
result in serious defects of speech. The shape of 
the hard palate, the dental arch, and the condition 
of the teeth all affect the character of the speech. 
A short lingual frenum or any deformity of the 
lingual muscles not only causes defective speech, 
but may make speech so disagreeable as to greatly 
delay its development and thus interfere with the 
child's mentality. Enlarged faucial tonsils and 
adenoid vegetations in the vault of the pharynx 
have long been supposed to interfere in some 
mysterious way with the mental development of 
children; but they probably interfere with mental 
development only so far as they impair the patient's 
physical condition and obstruct the development 
of normal speech. 
Another common cause of these defects of 
speech is the paralysis that often follows diph- 
theria and the various infectious fevers prevalent 
in children. This paralysis may be of only short 
duration, and yet if it come during the formative 
speech period, it is sure to leave its deleterious 
influence. It is during the earlier years of adoles- 
cence that these irregularities in the peripheral 
organs of speech do harm; and although they may 
disappear altogether after a few years, as is some- 
times the case with hypertrophied tonsils, or they 
may be removed by surgical interference later in 
life, yet the defects of speech of which they were 
the direct cause remain as fixed physical habits 
until they are corrected by suitable training. 
This is well illustrated by those cases having 
cleft palate. If the operation for the closure of 
the cleft is delayed until after the formative speech 
period and until that peculiar speech characteris- 
tic of cleft palate is fully established, it will have 
little or no effect upon the speech, however well the 
deformity may be corrected. This fact would seem 
to indicate that it is not so much the cleft palate 
that causes the defective speech, as the abnormal 
muscular action that is the direct result of the 
cleft palate. However that may be, this abnor- 
mal muscular action must be corrected after the 
two halves of the palate are put in apposition if 
improvement in speech is to be effected. 
Treatment.-In discussing the treatment of 
stammering it was found that the object to be 
attained was the correction of a faulty coordina- 
tion between the vocal and the oral articulating 
mechanisms, and indirectly, perhaps, between the 
muscles within one or the other of these two 
mechanisms. In pseudolalia the lack of coor- 
dination is entirely within the oral articulating 
mechanism. There is a faulty action in some of 
the muscles of the lips, the tongue, or the palate; 
and whatever may be the cause of this faulty 
muscular coordination, there is always a corre- 
sponding defective action in the nerve centers that 
preside over these mechanisms. 
A careful physical examination of the patient 
must first be made, with a view to determining the 
cause of the defect, always keeping in mind that 
this cause may have existed only in the past and 
during the formative speech period. All struc- 
tural peculiarities of the articulating organs should 
be carefully noted, and any obstructive irregulari- 
ties corrected or removed. When this is accom- 
plished, muscle training should be given, with a 
view to correcting the faulty action and establish- 
ing correct coordination. A lack of uniformity is 
often found in the development of these muscles, 
and this condition may be corrected by suitable 
voluntary exercises entirely independent of speech. 
For instance, muscles of the lips or of the tongue 
that have been entirely involuntary may be 
brought under control of the will and made to act 
independently of others, and thus be trained to 
perform their natural functions. This muscle 
training is an important factor in all speech defects, 
not only on account of its value in harmonizing the 
action of the muscles themselves, but also on 
account of the fact that it serves as a direct stimu- 
lus to the development of the cerebral areas that 
preside over the muscles, and the general mental 
development resulting from these exercises is 
sometimes very marked. 
Exercises for the correction of the special defects 
that may exist in each individual case should fol- 
low this muscle training. Speech is voice articu- 
lated or molded into certain definite shapes or 
forms. The vocal mechanism furnishes the voice, 
and the oral articulating mechanism the molds into 
which the voice may be regarded as being poured. 
Each syllable of speech requires a separate and 
distinct adjustment of the articulating organs, and 
those syllables that are composed of two or more 
primary elements require for and during their 
utterance certain variations in the molds. For 
instance, the syllable " m-a-t" has in it three pri- 
mary elements, for each of which a separate mold 
is required; but in the utterance of this syllable 
these elements follow one another in quick succes- 
sion and close sequence, and therefore these pri- 
mary elements must be made to follow one another 
so closely as to form what is practically one vari- 
able mold, upon the structure and formation of 
which depends the character of the resultant 
speech. 
If any part of this mold is imperfect in its forma- 
tion, there will be corresponding defect in the artic- 
ulation of the syllable. For instance, if the first SPERMATIC CORD, DISEASES 
SPINA BIFIDA 
primary mold required for the physiologic sound 
represented by " m " is omitted, the syllable will be 
"decapitated"; and if the last sound represented by 
the letter "t" is omitted, it will be " decaudated," 
and if the three primary molds are improperly 
formed and coordinated, the syllable will be 
" mutilated." 
The decapitation, decaudation, and mutilation 
of syllables are phenomena designated pseudolalia, 
and in the treatment of this affection the proper 
formation and coordination of the primary molds of 
speech and their coordination into what have been 
called the variable molds required for the utterance 
of syllables and words must be taught. To do this 
one must have an accurate knowledge of the anat- 
omy and physiology of the organs of speech, and 
the location of each muscle; and he must be able to 
form a clear mental picture of the exact position of 
the organs of articulation required for the forma- 
tion of the primary molds for the elements of speech 
and their coordination into the variable molds for 
the syllables and words. 
The patient must be taught the precise volun- 
tary muscular action required for the formation of 
these molds. He must be shown, for instance, how 
to shape the lips and where to place the tongue 
for each element of speech in which he may be 
found deficient; and thus, by frequent repetition of 
this voluntary control of the organs of speech, he 
may be trained to speak automatically with great 
accuracy. 
It will be observed, therefore, that the principle 
underlying the treatment of all defects of speech 
consists in the establishment of an accurate volun- 
tary muscular control of the organs, this control to 
be continued until the faulty processes or habits of 
speech have been entirely eradicated, and the new 
and improved methods become habitual and 
automatic. See Aphasia. 
SPERMATIC CORD, DISEASES.-Torsion of the 
spermatic cord-i. e., a twisting of the cord so that 
the epididymis is felt in front instead of behind the 
body of the testis-is occasionally met either in a 
testis to all external appearance previously nor- 
mal, or in a testis retained in the inguinal canal. 
The twisting has been attributed to spasm of the 
cremaster. If unrelieved, the testicle will atrophy 
or necrose. 
Symptoms.-The torsion is attended by a tender 
and painful swelling in the groin or scrotum, dull 
on percussion, irreducible, and without impulse on 
cough, the symptoms generally coming on sud- 
denly after great strain or exertion. Vomiting is 
nearly always present, and there may be constipa- 
tion. Thus, when the testis is retained, a stran- 
gulated hernia is very closely simulated. 
Treatment.-When seen early, the cord may be 
readily untwisted if the testis is in the scrotum, the 
symptoms at once disappearing. If the testis is 
in the groin or inguinal canal, it should be removed 
and the canal and ring closed by sutures. 
See also Hematocele, Hydrocele, Testicle, 
Varicocele. 
SPERMATOCELE.-See Hydrocele. 
SPERMATORRHEA.-See Nocturnal Emis- 
sions. 
SPERMATOZOA.-See Seminal Stains. 
SPERMIN.-Spermin has been found in the 
form of a phosphate in the thyroid and thymus 
glands, the spleen, the ovaries and the blood, as 
well as in the testes. Poehl believes it to be an 
alkaloidal product of the retrogressive metamor- 
phosis of albumins (a leukomain), and a most pow- 
erful intraorganic restorative of the oxidizing prop- 
erties of the blood. He states that it should not 
be regarded as a specific for any particular malady, 
but should be used as a means of promoting oxida- 
tion in the body. It has been employed with de- 
cided benefit in ataxia and delirious epilepsy, as a 
tonic in tuberculosis also in senile marasmus and 
the nervous affections of the aged. The hydro- 
chlorate is used hypodermically, in doses of 1/8 
grain twice daily, in the morning and at noon, avoid- 
ing evening administration, as it may cause insom- 
nia. No reaction follows its injection. 
SPHACELODERMA (Dermatitis Gangrenosa, 
Spontaneous Gangrene of the Skin).-See Derma- 
titis Gangrenosa Infantum, Raynaud's Disease. 
SPHENOIDAL SINUSES, DISEASES.-See Nose 
(Accessory Sinuses). 
SPHYGMOGRAPH.-See Pulse. 
SPIDER-BITE.-See Bites and Stings. 
SPIGELIA (Pinkroot).-The dried rhizome and 
roots of S. marilandica. A popular vermifuge, 
generally adminstered with senna. Should be 
employed with the usual precautions as to feedings, 
and a purge should be administered while the 
worm is narcotized, to carry it out of the bowel. 
In large doses it is an uncertain cathartic. Poison- 
ing is manifested by palsy of spinal origin, the 
respirations becoming slow as death approaches, 
and finally ceasing simultaneously with the action 
of the heart. Vertigo, dimness of vision, dilated 
pupils, dyspnea, convulsions, and spasms are lesser 
phenomena. Dose, 30 grains to 2 drams. S., 
Flext. Dose, for a child, 10 to 20 minims; for an 
adult, 1/2 to 2 drams. S., Infus., Comp., "worm 
tea," "pink and senna," unof.; spigelia 15, senna, 
fennel, each 10, manna 30, water 500. Dose, 11/2 
to 5 ounces. 
SPINA BIFIDA. (Hydrorrhachis).-A congeni- 
tal deficiency in the bony covering of the spinal 
cord, or failure of the spinal laminae to unite, 
present in about one in every 1000 births. Some- 
times there is a small congenital gap in the spine, 
the cord and membranes remaining in the canal 
{spina bifida occulta); the skin is frequently in- 
dented over this defect and the dimple filled with 
hair. These cases need no treatment unless there 
are symptoms of pressure on the cord, when the re- 
moval of such compression, which may be due to 
hypertrophy of the skin and subjacent soft parts, 
would be indicated. In 2 percent of the cases the 
cleft is wide, the skin is absent, and the cord pro- 
trudes through the opening, its central canal com- 
municating with the surface of the body {myelo- 
cele). This condition is not compatible with exist- 
ence. In 10 percent the membranes alone escape 
through the opening {meningocele), but in the vast 
majority (about 75 percent) there is also a portion 
of the cord in the protuberance {meningomyelocele), 
and very rarely the tumor is the result of a dilata- SPINA BIFIDA 
SPINAL CORD, INJURIES 
tion of the central canal of the cord (syringomyelo- 
cele). The last variety is often situated laterally. 
More than one vertebra is usually fissured, and 
cases have been reported in which all the vertebrae 
were involved. Rarely the body of the vertebra 
is implicated (anterior spina bifida). One-half 
of all cases occur in the lumbar region and more 
than one-third in the lumbosacral or sacral portion 
of the spine. (Stewart). 
The coverings of the sac may be healthy skin, 
but more commonly normal skin is only found at 
the sides, the central portion consisting of a thin 
bluish membrane. Sometimes a slight depression 
is seen on the lower part of the sac at the spot 
where the cord terminates in the wall. This is 
called the umbilicus, and at its bottom the central 
canal of the cord has at times been seen to open. 
In some instances there is no protrusion, but 
rather a depression in the situation of the cleft 
between the vertebrae (spina bifida occulta) the 
cleft being occupied by the blended membranes, 
cord, and skin, and the spot covered with a tuft of 
hair. In obscure paraplegias, contractures, and 
deformities of the feet the back should be exam- 
ined, since this condition may be present but has 
been overlooked by the mother. 
Symptoms.-The swelling is usually of a globu- 
lar or oval shape, translucent, sessile or slightly 
pedunculated, and flaccid, but becomes tense and 
distended on coughing or crying. Pressing upon it 
sometimes causes the fontanels to swell up, and 
may produce convulsions. When the spinal cord 
and large nerves are involved, there may be par- 
alysis of the extremities or of the bladder or rectum. 
The gap between the laminae of the vertebrae may 
at times be felt on pressing on the sac. As a rule, 
these tumors show a great tendency to enlarge, 
and rupture spontaneously, in which case death 
usually follows from the draining away of the 
cerebrospinal fluid and septic meningitis. Death, 
however, is sometimes due to marasmus and defect- 
ive nutrition. When a spontaneous cure takes 
place, it is usually due to the gradual shrinking of 
the sac. 
Diagnosis.-Its congenital origin will at once 
distinguish a spina bifida from a new growth devel- 
oped subsequently to birth; and its situation in the 
middle line, translucency, increase of tension on 
straining, and the gap between the laminse, when 
this can be felt, will usually serve to diagnose it 
from other congenital tumors. 
Treatment.-As there are no means of accurately 
determining that the spinal cord is not in the sac, 
it has hitherto not been considered safe to attempt 
excision or ligation, although these operations 
have at times been attended with success. Re- 
peated tappings are very fatal. The treatment 
usually employed, except when the spina bifida 
is very small or is apparently undergoing a sponta- 
neous cure, when it should be left alone, is to inject 
the sac with Morton's iodoglycerin fluid. This 
method when successful causes the tumor to shrink, 
and most closely follows the process of nature 
when a spontaneous cure occurs. The injection 
is best performed when the child is two months old; 
but it may be done earlier if the sac threatens to 
burst. The best results may be expected when 
there is no hydrocephalus or paralysis, and the sac 
is covered by healthy skin. It is contraindicated 
when there is advanced marasmus, great and 
increasing hydrocephalus, and intercurrent disease. 
The child should be placed on its side, and the 
puncture made obliquely through healthy skin on 
one side, and the base of the tumor, and not 
through the thin and imperfectly formed skin, 
which nearly always covers the sac in the middle 
line, the object being to avoid wounding the 
expanded spinal cord, and the subsequent leak- 
age of the cerebrospinal fluid. About a dram of 
the iodoglycerin fluid (iodin (10 grains), iodid of 
potassium (30 grains), glycerin (1 ounce)) should be 
injected, and the injection repeated in a fortnight 
if the first trial is not successful. The fluid con- 
tained in the sac should not be drawn off before 
the injection. The advantage of Morton's fluid 
over tincture of iodin alone is that, owing to the 
glycerin it contains, it becomes uniformly diffused 
over the sac-walls. The injection of iodoglycerin 
is not unattended with danger; therefore, when the 
sac is small and its walls are thick and it is not 
increasing in size, beyond protecting it with a 
metal or leather shield, no further treatment 
should be attempted. Mayo Robson advocates 
excision in all cases except when there is well- 
marked paraplegia, hydrocephalus, or marasmus, 
or when the tumor is small and well covered by a 
firm pad of integument. In spinal meningocele he 
makes skin flaps, removes the sac, ligates or sutures 
the base, and brings the flaps together by suture. 
In meningomyelocele he separates the skin from 
the sac, opens and dissects out the sac, taking care 
that the lines of suture in the meninges and skin 
are not opposite. 
SPINAL CORD, ANESTHESIA.-See Intra- 
spinal Anesthesia. 
SPINAL CORD, DISEASES.-These are con- 
sidered under their special headings. See Amyo- 
trophic Lateral Sclerosis, Caisson Disease, 
Friedreich's Ataxia, Locomotor Ataxia, Mus- 
cles (Progressive Atrophy, Progressive Dystrophy), 
Myelitis, Paralysis (Acute Ascending, Bulbar, 
Infantile), Paraplegia, Lateral Sclerosis, 
Syringomyelia, etc. 
SPINAL CORD, INFLAMMATION.-See Myel- 
itis. 
SPINAL CORD, INJURIES. Contusion of [the 
Spinal Cord (Hematomyelia).-Hemorrhage into 
the substance of the cord is nearly always the 
result of forced flexion, and occurs naturally in the 
region in which fracture by indirect violence is 
most common. Sometimes the similarity of ori- 
gin is shown by their occurrence together, but 
independently of each other. It is possible, how- 
ever, that it may be caused by direct violence. 
The hemorrhage nearly always lies in the gray 
substance of the cord, because this is the softest 
and the most vascular part, and it may occupy 
an indefinite length. The effect is immediate, 
becoming intensified later, as the hemorrhage 
extends. Motion and sensation are lost over a 
corresponding area; reflex action is suspended for a 
time, but rarely as completely as when the cord is SPINAL CORD, INJURIES 
SPINAL CORD, INJURIES 
crushed; and then later, as the circulation around 
the injured area becomes more active, hyper- 
esthesia sets in; motor disturbances are rare. The 
subsequent course depends chiefly upon the degree 
of the primary injury. The extravasated blood 
may be in great measure absorbed, leaving a cer- 
tain degree of anesthesia, with paralysis or spastic 
rigidity of the muscles corresponding to the part 
of the cord that has been destroyed; or, on the 
other hand, red softening and ascending myelitis 
may follow, the paralysis extend higher, bed-sores 
and cystitis set in, and, if the injury is in the cervi- 
cal region, phenomenal temperatures, just as when 
there is a fracture. 
Wounds of the spinal cord are rare in civil prac- 
tice, but they may be produced by stabs, the 
weapon passing between the arches of the verte- 
brae, possibly notching or incising them as it does 
so; or by gunshot injuries. The symptoms in 
either case depend upon the seat and the extent of 
the injury, and only differ from those of crushing 
of the spinal cord in fractures by their proneness to 
inflammation and suppuration. 
Compression.-This is much more rare; it may be 
caused by a lamina driven in, though when this 
occurs the delicate nervous tissue is almost sure to 
be utterly crushed; or by hemorrhage, either 
inside the theca or between it and the bones (it is 
impossible to distinguish one from the other); or 
later it may result from inflammation, as in Pott's 
disease. If due to bone, the symptoms are imme- 
diate ; if to hemorrhage, there is a distinct interval 
before they commence, and they progress from 
below upward, affecting the leg first, and then the 
trunk, until the respiratory muscles are involved. 
The loss of motion is more marked than that of 
sensation, but it is rarely so definite as in contusion; 
pain along the course of the nerves, hyperesthesia 
extending around the trunk, and muscular tremors 
are more frequent. In many instances the blood 
is absorbed again and the symptoms subside; 
occasionally it accumulates to such an extent as to 
prove fatal, either from its pressure or from second- 
ary softening and degeneration. See Spine (Dis- 
eases, Injuries). 
Concussion.-This injury occurs practically under 
the same conditions as contusion, and can only be 
distinguished from it by the symptoms being gen- 
eral, not confined to any one portion of the spinal 
cord, and by their passing off within a few hours. 
Afterward, when the immediate symptoms have 
disappeared, hyperemia may set in, as in concus- 
sion of the brain. If there is no contusion, as 
very rarely happens, this may be merely tran- 
sient, and under proper treatment subside without 
leaving behind any serious result; but if the part is 
not kept at rest, or if there is severe contusion, it 
may increase, and either run to inflammation or 
lead to softening and degeneration. 
Railway Spine.-Railway accidents are not infre- 
quently followed by a peculiar train of symptoms, 
which have been grouped together under the name 
"railway spine," justly stigmatized by Page as 
absurd. The symptoms do not set in immediately 
and are not those of any gross lesion of the cord, 
such as contusion or inflammation. As a rule, they 
do not appear for 3 or 4 days; then, after lasting 
some time, they either begin to subside or steadily 
grow worse. The chief difficulty is to distinguish 
them from locomotor ataxia and chronic meningo- 
myelitis, both of which may undoubtedly follow 
injuries to the back. If, however, sufficient at- 
tention is paid to objective symptoms, to the 
distribution of areas of anesthesia, for example, 
and the electric reactions of muscles, it can usually 
be surmounted. Railway accidents are always 
accompanied by an extreme degree of shock that 
occasionally, but fortunately not very often, grows 
worse and worse; the patient becomes more feeble, 
and without being able to assign any definite reason 
for it, or find any gross lesion, death ensues after a 
few weeks or months, just as sometimes happens 
after a severe mental shock. More frequently there 
is a certain amount of improvement for a time, but 
not perfect recovery. The extreme depression 
passes off, but the patient remains weak and feeble, 
unable to control himself or to exercise deliberate 
judgment, with mental capacity and bodily vigor 
alike impaired. The symptoms are of the most 
varied character. Some, such as palpitation, flush- 
ing, alternate sensation of heat and cold, and 
menorrhagia, may be accounted for by the disorder- 
ed working of the vasomotor system; others, like 
sleeplessness, dreaming, headache (often posterior), 
irritability of temper, emotional display, noises in 
the ears, and failure of sight, are due to interference 
with the blood supply of the brain and the organs 
of special sense. The bodily strength fails; gas- 
trointestinal disturbances are present; the patient 
becomes worn and emaciated; the cerebral symp- 
toms grow more pronounced, and at last he becomes 
utterly broken down in health, feeble in mind as 
well as body, and aged before his time. This 
history is not in any way peculiar to railway acci- 
dents. It may be induced by injuries of all kinds, 
especially in those who from heredity or for other 
reasons are in any way predisposed to the occur- 
rence of nervous disorders. It is not uncommon, 
for example, after severe and prolonged mental 
worry; it may even follow a single shock, as noted 
by Moullin. 
In another class the symptoms resemble those 
ordinarily grouped together as hysteric. There 
may be epileptiform attacks from time to time, 
with insanity, melancholia, or suicidal impulse. 
Anesthesia and hyperesthesia may occur, affecting 
the special nerves as well as those of ordinary sen- 
sation. In other instances muscular paralysis, af- 
fecting physiologic groups rather than anatomic 
ones, or spasmodic contraction is present, the elec- 
tric reaction remaining unaltered. Retention of 
urine and aphonia are very common; and numerous 
other symptoms are met from time to time- 
pains in the joints, for example, of the most 
excruciating character, without any objective 
sign, dysphagia, torticollis, closure of the 
jaws, etc. 
If in any of these groups of cases there is, in ad- 
dition, a severe sprain of the muscles or ligaments 
of the neck and back, so that every movement is 
attended with pain, the difficulty of proving that 
the injury is limited to external structures, and SPINAL CORD, INJURIES 
SPINAL CORD, LOCALIZATION 
that the spinal cord is not involved as well, may be 
imagined. The local symptoms, the stiffness, 
rigidity, and pain, grow worse and worse as time 
goes on. If the hypnotic state continues, each 
suggests some further trouble, and it is almost 
impossible to distinguish between the real and the 
functional disorder. The desire to recover is often 
not genuine, even when it is present, and it is im- 
possible to obtain any assistance from the patient. 
If there is even a suspicion of chronic inflammation 
of the spinal cord, it is a serious matter to propose 
active measures. Time is thus wasted, and the 
muscles become more rigid from disuse; the ex- 
tra vasated blood becomes organized; adhesions 
are formed in all directions; and it ends in leaving 
a permanently crippled condition. 
The diagnosis from chronic inflammation of 
the spinal cord rests chiefly upon the absence of 
definite local signs. Stiffness and rigidity of the 
back are not leading characteristics of chronic 
meningitis. When this sets in, there are other 
symptoms, usually of an unmistakable character: 
There is pain along the course of certain nerves; or 
anesthesia and hyperesthesia of definite regions; 
special groups of muscles are wasted or paralyzed; 
the electric reactions are abnormal; the cutaneous 
reflexes are enfeebled or lost; in short, there is 
definite evidence of injury to nerves or centers in 
the cord, such as does not occur in sprains of the 
veretebral column alone, however severe the mental 
depression and bodily weakness may be (Moullin). 
SPINAL CORD, LOCALIZATION.-The following 
table (after Starr) shows the location of function 
in the different segments of the spinal cord: 
Segment. 
Second and third 
cervical. 
Muscles. 
Sternomastoid; trapezius; 
scaleni and neck; dia- 
phragm. 
Reflex. 
Hypochondrium ( ?). Sudden inspiration in- 
duced by sudden pressure beneath the low- 
er border of ribs. 
Sensation. 
Back of the head to the 
vertex. The neck. 
Fourth cervical. ... 
Diaphragm; deltoid; biceps; 
coracobrachialis; supinator 
longus; rhomboid; supraspin- 
atus and infraspinatus. 
Pupil. Fourth to seventh cervical. Dilata- 
tion of the pupil induced by irritation of 
neck. 
The neck, upper part of 
the shoulder, and outer 
part of the arm. 
Fifth cervical 
Deltoid; biceps; coracobra- 
chialis; supinator longus; 
supinator brevis; rhom- 
boid; teres minor; pectoralis 
(clavicular part); serratus 
magnus. 
Scapular. Fifth cervical to first dorsal. Irri- 
tation of skin over the scapula induces con- 
traction of the scapular muscles. Supinator 
longus. Tapping its tendon at wrist in- 
duces flexion of forearm. 
Back of the shoulder and 
arm. Outer side of the 
arm and forearm, front 
and back. 
Sixth cervical 
Biceps; brachialis anticus; 
pectoralis (clavicular part); 
serratus magnus; triceps; 
extensors of wrist and 
fingers; pronators. 
Triceps. Sixth to seventh cervical. Tapping 
elbow tendon induces extension of forearm. 
Posterior wrist. Sixth to eight cervical. 
Tapping tendons causes extension of hand. 
Outer side of the fore- 
arm, front and back. 
Outer half of the hand. 
Seventh cervical... 
Triceps (long head); exten- 
sors of wrist and fingers; 
pronators .of wrist; flexors 
of wrist; subscapular; pec- 
toralis (costal part); latissi- 
mus dorsi; teres major. 
Anterior wrist. Tapping anterior tendons 
causes flexion of wrist. Palmar. Seventh 
cervical to first dorsal. Stroking palm 
causes closure of fingers. 
Inner side and back of 
arm and forearm. Ra- 
dial half of the hand 
Eight cervical 
Flexors of wrist and fingers; 
intrinsic muscles of hand. 
Forearm and hand, 
inner half. 
First thoracic 
Extensors of thumb; intrinsic 
hand muscles; thenar and 
hypothenar eminences. 
Forearm, inner half. 
Ulnar distribution to 
the hand. 
Second to twelfth 
thoracic. 
Muscles of back and abdomen; 
erectores spin®. 
Epigastric. Fourth to seventh thoracic. 
Tickling mammary region causes retraction 
of the epigastrium. Abdominal. Seventh 
to eleventh thoracic. Stroking side of abdo- 
. men causes retraction of belly. 
Skin of chest and abdo- 
men, in bands running 
around and downward, 
corresponding to spinal 
nerve. Upper gluteal 
region. 
First lumbar 
Iliopsoas; sartorius; muscles 
of abdomen. 
Cremasteric. First to third lumbar. Strok- 
ing inner thigh causes retraction of scrotum. 
Skin over the groin and 
front of the scrotum. 
Second lumbar 
Iliopsoas; sartorius; flexors 
of knee (Remak); quadri- 
ceps femoris. 
Patella tendon. Striking tendon causes ex- 
tension of leg. 
Outer side of the thigh 
Third lumbar 
Quadriceps femoris; inner ro- 
tators of thigh; abductors 
of thigh. 
Front and inner side of 
the thigh. 
Fourth lumbar 
Abductors of thigh; adductors 
of thigh; flexors of knee 
(Ferrier); tibialis anticus. 
Gluteal. Fourth to fifth lumbar. Stroking 
buttock causes dimpling in fold of buttock. 
Inner side of thigh and 
leg, to the ankle. Inner 
side of the foot. 
Fifth lumbar 
Outward rotators of thigh; 
flexors of knee (Ferrier); 
flexors of ankle; extensors 
of toes. 
Back of the thigh and 
leg, and outer part of 
the foot. 
First to second 
sacral. 
Flexors of ankle; long flexors 
of toes; peronei; intrinsic 
muscles of foot; perineal 
muscles. 
Plantar. Tickling sole of foot causes flexion 
of toes and retraction of leg. Foot-reflex. 
Achilles tendon. Overextension of foot 
causes rapid flexion; ankle-clonus. Bladder 
and rectal centers. 
Back of thigh. Leg and 
foot, outer side. Skin 
over sacrum. Anus. 
Perineum. Genitals. SPINAL CORD, LOCALIZATION 
SPINAL CORD, TUMORS 
Motob. 
Sensory. 
Reflex. 
Sternomastoid. 
Trapezius. 
} Diaphragm. 
1 Serratus 
j Shoulder 
Arm 
Hand 
(ulnar, lowest 
muse. 
J. 
Neck and scalp. 
Neck and shoulder. 
Shoulder. 
Arm. 
Hand. 
Scapular. 
I 
ntercostal 
muscles. 
F 
ront of thorax. 
Ensiform area. 
Epigastric. 
Abdominal 
muscles. 
Abdomen. 
(Umbilicus, 10th). 
Abdominal. 
f 
i 
lexors, hip. 
Extensors, kne 
} Adductors. 
Abductors 
Extensors (?). 
Flexors, knee (? 
Muscles of leg n 
foot. 
'erineal and anal 
hip. 
). 
roving 
muscles. 
r 
I 
. I 
1 Butte 
) part 
Iroin and 
(front). 
''high 
.eg, inner 
Buttock 
Back oi 
T 
Leg 
and 
foot 
'erineum 
cks, upper 
scrotum 
outer side. 
front. 
inner side. 
side. 
s, lower part. 
thigh. 
except inner 
part. 
and anus. 
Cremasteric. 
j- Knee-joint. 
J 
' Gluteal. 
Foot-clonus. 
Plantar. 
Skin from coccyx to 
anus. 
Diagram and Table Showing the Approximate Relation to the Spinal Nerves of the Various Motor, Sensory, 
and Reflex Functions of the Spinal Cord. {Arranged by W. R. Gowers, from anatomic and pathologic data.) 
SPINAL CORD, TUMORS.-The diagnosis of 
tumors of the cord and its membranes necessitates 
a knowledge of the symptoms of tumors involving 
the spinal column. It, therefore, seems appropri- 
ate to consider tumors of all these structures under 
the same general heading. 
Tumors of the Spinal Column.-Tumors of the 
spine resulting from spina bifida and other congeni- 
tal tumors are discussed under their various heads. 
Etiology.-Tumors of the spine are exceedingly 
rare before the thirtieth year. They are not fre- 
quent at any time of life, but are found most com- 
monly during the fifth decade. They occur with 
slightly greater frequency in the male than in the 
female. Injury to the spine is undoubtedly the 
exciting cause in some instances. 
Pathologic Anatomy.-Carcinoma-either of the 
scirrhous or encephaloid variety-osteosarcoma, 
and sarcoma are the most frequent growths of the 
spine. Tumors of the spine may be primary or 
secondary. Cancerous growths of this region may 
be secondary, especially when the primary lesion 
is in the breasts, stomach, or mediastinum. 
According to Gowers and others, primary growths SPINAL CORD, TUMORS 
SPINAL CORD, TUMORS 
are more likely to begin in the bodies of the verte- 
brae. If the bodies of the vertebrae are weakened 
by the neoplasm, angular curvature of the spine 
may take place, as in caries. The spinal nerves 
may suffer by compression, inflammation, or infil- 
tration (Gowers). The spinal cord is rarely, if 
ever, infiltrated; but it is often compressed by the 
growth extending into the spinal canal. In nearly 
all advanced cases the cord is inflamed opposite 
the seat of the growth. 
Symptoms.-These result from involvement of 
bone, the spinal nerves-which rarely ever escape 
-and from compression and inflammation of the 
cord. The latter may appear early or not until 
late in the course of the disease. The bone symp- 
toms differ from those of caries in that among the 
former there may be a discoverable tumor, espe- 
cially in the cervical region, and a greater severity 
of the spinal pain, well pronounced on bending the 
spine in different directions. 
The nerve-root symptoms, especially pain, 
which is usually an early symptom, are often pro- 
nounced, Radiating pains and areas of hyper- 
esthesia and anesthesia are frequently more 
marked than in caries or in tumors of the mem- 
branes. The cord symptoms are those of myelitis. 
In some instances complete paralysis takes place 
within a few days or a few weeks after the first 
cord symptoms appear. 
Diagnosis.-The diseases likely to be confounded 
are caries and tumor, after the symptoms point 
unmistakably to organic disease of the spine. The 
presence of a tumor, when this can be felt, a pri- 
mary growth in some other portion of the body, the 
severity of the pain, both bone and nerve-root, 
and in cases of cancer the rapid progress of the dis- 
ease, are points in favor of a tumor. 
Duration and Prognosis.-Carcinoma of the spine 
runs a rapid course, and results in death in a few 
months. Life is rarely prolonged a year. Slowly 
growing tumors may run a course of one to several 
years. Gowers quotes a case that lasted 13 years, 
death finally taking place from meningeal hemor- 
rhage. Death usually takes place from myelitis. 
Unless the tumor is so situated that it may be 
removed, which is, unfortunately, rarely the case, 
death invariably results. 
Treatment.-In inoperable tumors of the spine 
the treatment resolves itself into prolonging life by 
giving nourishing food, and in making the patient 
as comfortable as possible by the judicious use of 
various anodynes and analgesics, of which, unfor- 
tunately, morphin is our main reliance. In cases 
in which the pains are not too severe, the following 
formula has postponed the use of morphin until 
late in the disease: 
I). Extract of cannabis indica, gr. 1/6 
Sulphate of codein, gr. j 
Phenacetin or acetanilid, gr. iij 
Citrated caffein, gr. ij. 
In capsule, and repeated only as often as it 
is absolutely necessary for the relief of pain. 
Codein is much less objectionable than morphin 
in those cases in which the pain can be relieved 
by it. 
Tumors of the Cord and of its Membranes. 
The symptoms of tumors of the cord are so 
similar to those of the membranes that it will be 
more convenient to study these together; and in 
the section on diagnosis to endeavor to bring out 
the differential points between an unmistakable 
case of tumor of the cord and one of the mem- 
branes. In many cases, especially when the neu- 
rologist is consulted, it is only possible from the 
symptoms present to make a diagnosis of intra- 
spinal tumor, irrespective of the primary seat of 
the lesion. In others, however, by a careful study 
Showing the Relation of the Tumor to the Cord 
which it had Displaced to the Left.-(Eskridge.) 
A. Tumor. B. Eroded end of fourth rib. The neoplasm 
had apparently taken its origin on the anterior surface of the 
body of the fourth dorsal vertebra and extended into the 
spinal canal, completely separating the end of the rib from 
the vertebra. 
of the history, with especial reference to the initial 
symptoms and to the manner of development of 
additional ones, and by thorough, repeated, and 
systematic examinations, a fairly definite diag- 
nosis can be made between tumor of the cord and 
of the membranes. Theoretically, the symptoms 
of tumor in the substance of the cord are such as 
denote destruction of tissue and abolition of func- 
tion; while those that result from a growth in the 
membranes are such as one would expect from 
irritation of tissue-perversion of function. Prac- 
tically, however, the early symptoms of tumor of 
the cord may be irritative in character, and in the SPINAL CORD, TUMORS 
SPINAL CORD, TUMORS 
advanced stages of tumor of the membranes the 
function of the cord may be totally abolished. 
Etiology.-Intraspinal tumors may occur at any 
time of life. They are most frequent between the 
fifteenth and the forty-fifth years. In an analysis 
of 50 cases Mills and Lloyd found 14 percent before 
the twentieth year. They are slightly more fre- 
quent in the male than in the female. Syphilis 
and tuberculosis are diathetic conditions that may 
lead to the development of tumors of the cord or 
of the membranes. Traumatism has been cred- 
ited with causing many of the intraspinal tumors. 
Growths here are often secondary to similar ones 
in other portions of the body. In the majority of 
cases no real cause can be found. 
Pathologic Anatomy.-In the substance of the 
cord sarcoma and the different varieties of it, 
especially glioma, are the most frequent tumors 
met. Solitary tubercles, syphiloma, and a few 
other growths may take place here. In the mem- 
branes fibroma, sarcoma, fibrosarcoma, myxoma, 
psammoma, tubercle, syphiloma, and several 
other varieties occur. Neuromata are found on 
the spinal nerve-roots arid the cauda. The dorsal 
region is the most common seat of tumors. Fi- 
broma is rarely more than an inch or two in length, 
and its long axis corresponds with that of the 
spinal canal. The sarcomata and some other 
growths may be several inches in length, and in 
rare instances have extended nearly throughout 
the entire length of the cord or spinal canal. Tu- 
mors may arise from the fatty substance between 
the bone and dura-especially lipoma-from the 
external or internal surface of the dura, from the 
soft membranes, or from the substance of the cord 
itself. In some instances a tumor takes its origin 
from the soft tissues outside of the spinal canal 
and grows inward through the intervertebral fora- 
mina. Extradural growths have always been 
found to be single; the intradural ones, while often 
single, may be multiple. Tumors of the mem- 
branes, while usually small, may be limited in size 
only by the width of the spinal canal; hence tumors 
of the cauda often attain a larger size than those 
occurring higher up in the spinal canal. Tumors 
of the substance of the cord are usually small, and 
generally begin unilaterally. Growths of the 
membranes compress the nerve-roots, the cord, 
and often give rise to meningeal irritation. The 
growths are usually unilateral, but in some 
instances they involve the membranes so as com- 
pletely to encircle the cord. 
Symptoms.-The tissues irritated, compressed, 
or destroyed in intraspinal tumors may vary so 
much in different cases that the symptoms are 
rarely the same in any two. A knowledge of the 
numerous conditions that may exist within the 
spinal canal, although apparently at first confusing, 
will often enable one, by a careful analysis of all the 
symptoms in an individual case and a minute 
sifting of the details of the history of the disease, 
to make a fairly accurate diagnosis. 
The early symptoms may be from unilateral 
irritation of the spinal nerve-roots, sensory or 
motor; from unilateral irritation of the membranes, 
or of the membranes and nerve roots; from uni- 
lateral irritation of nerve-roots, membranes, and 
cord; from unilateral irritation of the cord alone; 
from bilateral irritation of the nerves and mem- 
branes; from bilateral irritation of the nerves, mem- 
branes, and the cord, or from bilateral irritation 
of the cord alone. The symptoms are more de- 
cided in character-both of irritation and destruc- 
tion-in infiltrating than in noninfiltrating growths. 
The symptoms vary in character according to 
the region of the spinal canal in which the tumor 
is situated; they are modified by the structures in 
which the tumor takes its origin, especially whether 
the cord is primarily the seat of the growth or is 
affected by compression; and finally the rapidity 
with which the symptoms develop depends upon 
whether the tumor is slow or rapid in its growth. 
The symptoms may be divided into nerve-root, 
meningeal, and cord symptoms. In tumor of the 
spinal cord the cord symptoms are usually the pri- 
mary ones. In rare cases in which the growth is 
situated in the posterior portion of the cord, usu- 
ally unilateral and involving the nerve-root fibers 
from the posterior horn, the early symptoms may 
be of a nerve-root character. Extramedullary tu- 
mors give rise to nerve-root and meningeal symp- 
toms before those of the cord are manifest. 
Nerve-root Symptoms.-These are usually unilat- 
eral and sensory in character early in the course of 
the disease. If the cauda is affected, the symp- 
toms are bilateral and affect the legs and feet; if 
the tumor is in such a position as to involve some 
of the nerves of the lumbosacral plexus, the pain 
will be felt in one leg; if the brachial plexus is af- 
fected, the pain radiates in one arm; if some of 
the trunk nerves are the seat of the irritation, the 
early symptom may be pain at the distal portion of 
one or two nerves, without pain or tenderness in 
any other portion of those nerves for a while. 
In some cases hyperesthesia throughout the 
distribution of the affected nerve or nerves is well 
marked; and later anesthesia replaces the hyperes- 
thesia. In those cases in which the nerve-roots 
become infiltrated by the growth, wasting of the 
muscles supplied by the affected nerves takes 
place, and there may be the reactions of degenera- 
tion. These phenomena are especially pronounced 
in the legs in tumors of the cauda. The skin over 
the area of distribution of the inflamed or degener- 
ated nerves may show changes, such as herpetic 
eruptions, glossiness, and thickening. Meningeal 
irritation is evidenced by pain in the back, tender- 
ness on pressure, and muscular twitching. The 
pain and tenderness in the back are not nearly so 
pronounced as they are in tumor of the vertebrae, 
nor are movements of the spine so agonizing. The 
pain is entirely absent in some cases. Tenderness 
may not be elicited unless the pressure is firm 
enough to produce some flexing of the spinal col- 
umn. Rigidity of the muscles of the back is 
rarely pronounced except in those cases in which 
there is considerable involvement of the spinal 
nerves and usually of the membranes. The nerve- 
root and meningeal symptoms are among the 
earliest in extramedullary tumors. They are at 
first usually unilateral and later bilateral. In those 
cases in which the tumor is situated in regions of SPINAL CORD, TUMORS 
SPINAL CORD, TUMORS 
the canal that are narrow, as in the upper cervical 
and dorsal regions, the indirect symptoms of nerve- 
root origin arising from the cord being crowded 
against the bones of the opposite side of the canal, 
may be more pronounced late in the disease than 
those that arise from the direct irritating effects of 
the growth. Eskridge has seen 2 cases in which 
the tumor had caused displacement of the cord, 
and crowded the nerve-roots of the opposite side 
against the bones of the spinal canal; and in each 
the indirect symptoms were as great as, if not 
greater than, the direct ones. 
Cord symptoms manifest themselves early in in- 
tramedullary growths, and are usually at first uni- 
lateral in character, but soon become bilateral. 
If the tumor begins in one of the posterior horns 
of the cord, nerve-root symptoms of a sensory 
nature are the earliest. These symptoms, how- 
ever, differ from those caused by an extramedul- 
lary tumor affecting principally a posterior nerve- 
root, in that in the former on the opposite side of 
the body from the one on which the nerve-root 
symptoms are manifest, and beginning at a level 
one inch or more below the level of the nerve-root 
symptoms, some disturbance of sensation, either 
subjective or objective, will be found, if carefully 
searched for early in the course of the disease, and 
cord symptoms develop about the same time that 
nerve-root symptoms are first complained of. In 
extramedullary tumors, on the other hand, nerve- 
root symptoms almost always precede cord symp- 
toms for weeks or months, except possibly in rare 
cases in which the tumor is small and so situated as 
not to impinge upon the nerves before some pres- 
sure is exerted upon the cord. In such cases the 
growth might be located anteriorly, posteriorly, or 
laterally. The tumor under such circumstances 
would necessarily be a slowly growing one, and the 
symptoms would be those of gradually increasing 
compression of the cord, irritative in character, 
and not indicating destruction of cord tissue for a 
prolonged period at least. In intramedullary 
tumors, with the exception noted, the symptoms 
would probably be unilateral, at first those of 
irritation, later leading to destruction of cord 
tissue and abolition of function. Such symptoms 
would not be preceded by those of nerve-root and 
meningeal irritation. If the cord symptoms begin 
unilaterally in intramedullary growths, they soon 
become bilateral. It is important to bear in mind 
that in intramedullary tumors beginning unilater- 
ally, while a well-defined case of Brown-S^quard 
paralysis, loss of motion on the side corresponding 
to the seat of the lesion, and loss of sensation on 
the opposite side is rarely seen, yet in nearly all 
of these the greatest loss of motion and disturb- 
ance of the deep reflexes, with weakened muscular 
sense, occur on the side corresponding to that on 
which the neoplasm is located; impaired sensation, 
subjective or objective, and disturbed superficial 
reflexes are most marked on the opposite side be- 
low the seat of the lesion in all those cases in 
which the tumor is situated above the lumbar 
enlargement. In some cases, especially in those in 
which the growth begins in the central canal, the 
symptoms are bilateral from the beginning. 
Nerve-root symptoms and rigidity of the muscles 
of the back are slight or almost entirely absent in 
intramedullary tumors. Muscular wasting and 
the reactions of degeneration are more common in 
intramedullary than in extramedullary tumors, 
except in those cases in which the growth origi- 
nates in the cauda, then the symptoms are bilateral 
from the beginning. 
Individual Symptoms. Motor.-Paralysis of 
more than a few muscles of one side of the trunk or 
of one limb rarely occurs in extradural tumors 
until cord symptoms develop. The exception to 
this is found in tumors of the cauda, in which case 
the paralysis is bilateral. The paralysis is usually 
a later symptom than pain in extradural tumors. 
Motor symptoms may precede the sensory by 
several weeks. Paralysis of the anal and vesical 
sphincters may take place early in tumors of the 
lumbar and sacral portions of the cord and in 
tumors of the cauda. Retention of urine may oc- 
cur comparatively early in intramedullary tumors 
above the lumbar region. Paralysis of the sphinc- 
ters only results late in the progress of tumors, 
intra- or extramedullary above the lumbar enlarge- 
ment, except in rare instances in which the in- 
flammation may descend and involve the lower 
portion of the cord. The ataxia, sometimes ob- 
served in extra- and intramedullary tumors of the 
dorsal region, is attended by pain in the back and 
other unilateral or bilateral symptoms of focal 
lesion of the cord. 
Reflexes.-The reflexes in extradural tumors 
before cord symptoms develop are abolished only 
in the region of distribution of the affected nerves. 
When cord symptoms develop either from extra- 
or intramedullary tumors, the reflexes are affected 
in the same manner that they are found to be in 
myelitis of the different portions of the cord. 
Rigidity of the back muscles is rare in intramedul- 
lary tumors, but it is common in extramedullary 
growths. Muscular wasting and the reactions of 
degeneration, except in isolated muscles, denote 
an intramedullary or a caudal tumor. 
Sensory Disturbances.-Pain is one of the earli- 
est and most pronounced symptoms of an extra- 
medullary tumor. It is usually at first unilateral, 
and radiates along the course of one or two spinal 
nerves. A tender point, or rather localized pain, 
is usually found at the distal portion of the affected 
nerves. Pain in the back, often severe in charac- 
ter, but rarely ever as agonizing as in tumor of the 
vertebrae, is frequently complained of in extra- 
medullary tumors, especially when the patient 
tries to bend the spine freely in different directions. 
It is not a pronounced symptom in intramedullary 
growths. Hyperesthesia at first and later anes- 
thesia are found in the area of distribution of the 
affected nerves. Dissociation of the sensory 
phenomena is common in tumors of the cord, and 
may be found in extramedullary tumors after the 
cord has become seriously affected by compression. 
It is not uncommon to have temperature sense 
abolished over areas in which tactile sense is pre- 
served. Pain and temperature sensations may 
both be abolished, and tactile sense preserved. 
Dissociation of the sensory phenomena is rarely so SPINAL CORD, TUMORS 
SPINAL CORD, TUMORS 
typical in extramedullary tumors as is the case in 
neoplasms of the cord. 
Vasomotor and Trophic Disturbances.-Either 
extra- or intramedullary tumors in the cervical 
region may give rise to inequality of the pupils and 
unilateral sweating, especially of the neck and head. 
Dilatation of the capillaries may take place on one 
side of the body in the parts below the seat of an 
intramedullary growth. Trophic disturbances 
may occur in the skin over the area of distribution 
of the affected nerves in extramedullary tumors. 
These may consist of herpetic eruptions, dryness, 
thickening, and harshness of the skin. The most 
marked trophic disturbances occur in tumors of 
the cauda and of the lumbar region of the cord. 
These are pronounced muscular atrophy, with the 
reactions of degeneration, bed-sores, and cystitis. 
In intramedullary tumors of the dorsal and cer- 
vical regions the trophic changes are largely limited 
to the parts on a level with the lesion. 
Vdriability of Symptoms.-These occur in both 
intra- and extramedullary tumors, but are most 
pronounced in the latter. The symptoms vary 
considerably in intramedullary tumors, but the 
changes are never so sudden or so great as those 
observed in the extramedullary variety. In the 
former the patient slowly, rapidly, and, in some 
instances, suddenly, gets worse, so that it becomes 
apparent that without a change in the course of 
the disease life cannot long continue. Gradually 
the patient begins to improve, and this goes on for 
several weeks. At the end of this time the patient 
seems to be in nearly as good condition as he was 
before the change for the worse. Such sudden 
changes and the pronounced improvement that 
follows them can only be explained on the theory 
of acute focal myelitis, which has subsided and 
been resolved, or of a local hemorrhage which has 
been absorbed. 
Course and duration of intraspinal tumors vary 
greatly. The course is shorter, and acute myelitis 
of a destructive character is more likely to occur 
in intramedullary than in extramedullary tumors. 
The intramedullary tumors usually progress stead- 
ily to a fatal termination more quickly than an 
extramedullary one. The average duration is 
from a few months to 2 or 3 years. Some excep- 
tionally rare cases last much longer than this. 
Most cases steadily grow worse from month to 
month, although the symptoms may show much 
variability during a period of several months. 
Diagnosis.-The questions to decide are: Is the 
trouble organic or functional? If it is organic, 
its character, or, in this instance, is it tumor? 
What is the location of the tumor: First, with 
relation to the bone; second, with reference to the 
cord itself; third, in regard to the membranes; and, 
lastly, opposite what segment of the cord does it 
lie? The final questions to determine, if possible 
are: What is the nature of the growth, and is it 
operable ? 
Is the trouble organic or functional? This ques- 
tion in the vast majority of instances will not be 
difficult to answer even early in the history of the 
case. In the majority of instances the symptoms 
are numerous and pronounced. They consist of 
spinal pain, tenderness, and lessened freedom of 
movement of the spinal column, radiating pains 
from the same level, muscular weakness and loss of 
reflexes at this level, and exaggeration of the 
reflexes below. All these symptoms first being 
unilateral in character soon become bilateral. 
In other words, there would be positive evidences 
of a focal lesion affecting the spinal column, mem- 
branes, nerve-roots, or cord. These are numerous, 
have been described under the head of symptoms, 
and are familiar to those who have become expert 
in examining for obscure affections of the spine 
and cord. 
Is the lesion a tumor? The diseases that should 
be considered and excluded before arriving at the 
conclusion that a tumor exists are: Hemorrhage 
into the cord; a transverse myelitis without com- 
pression of the cord; caries; aneurysm; cervical 
pachymeningitis; neuritis; traumatic injuries of 
the spine and cord; and, lastly, syringomyelia. 
Hemorrhage into the Substance of the Cord.- 
Hemorrhage that comes on suddenly, and gives 
rise to paralysis more or less complete in a few 
minutes, or few hours at most, after the first onset 
of the symptoms, and commonly ends in death 
from acute myelitis, may be mistaken for tumor 
of the cord. Tumor of the cord substance, espec- 
ially glioma or sarcoma, might be attended by 
hemorrhage, as is the case with reference to these 
tumors when situated in the brain. In such cases, 
however, the history would show that spinal cord 
symptoms had preceded the paralysis for weeks 
and months. The history of hemorrhage into the 
substance of the cord reveals traumatism or free- 
dom from spinal symptoms preceding the hemor- 
rhage, while sudden paralysis from tumor would 
be preceded by the history of spinal symptoms. 
Transverse Myelitis without Compression of the 
Cord.-In transverse myelitis without compression 
there are no nerve-root pains, spinal tenderness, 
or pain on bending the spinal column. The dis- 
ease begins, in the vast majority of instances, 
bilaterally, and all the functions of the cord below 
the seat of the lesion are greatly affected or almost 
completely abolished soon after the beginning of 
the initial symptoms. The reverse of nearly all 
of these phenomena obtains in the case of tumor 
of the membranes and bones, and in tumor of the 
cord, except the nerve-root pains and spinal ten- 
derness which are also absent in the majority of 
cases of intramedullary tumors. 
Caries of the Spine.-Pain, limited to one or two 
vertebrae, tenderness of the spinous process over 
the same region, nerve-root symptoms, muscular 
rigidity, and cord symptoms are common to caries 
and tumor of the vertebrae, membranes, and, to 
a less extent, to tumor of the cord. The intense, 
agonizing pain in the back, both when the patient 
is at rest and while the spine is being moved, is not 
found in caries. In the latter the nerve-root symp- 
toms are less marked than in tumor of the bone or 
membranes. They are absent in tumor of the 
cord. The symptoms are bilateral in caries, ex- 
cept in exceedingly rare cases. In tumor they are 
almost always unilateral early in the history of the 
disease. Rapid progress of the morbid process and SPINAL CORD, TUMORS 
SPINAL CORD, TUMORS 
failure to yield to rest would point to tumor. De- 
formity of the spine would exclude tumor of the 
cord or membranes, but not tumor of the bones. 
The history of syphilis or of the removal of a 
tumor from another portion of the body, espec- 
ially a malignant tumor of the breast, would be 
in favor of tumor. 
Aneurysm.-The advanced age of the patient, 
except when the subject is syphilitic, would be 
equally in favor of tumor and aneurysm. If the 
subject is young and syphilis can be excluded, 
aneurysm may also be excluded. If, by careful 
auscultation and palpation over the entire back, no 
aneurysmal bruit is detected, it is useless to con- 
sider aneurysm as a causative factor. 
Cervical pachymeningitis and intraspinal tumor 
have many symptoms in common. Pachymenin- 
gitis spreads over a larger vertical extent than does 
tumor, except in rare instances. The former more 
usually begins bilaterally than the latter, and 
gives rise to greater muscular rigidity than does 
tumor. Muscular wasting in tumor affects at first 
a limited group of muscles; pachymeningitis causes 
wasting in several groups. Tumor of the cord is 
not likely to be mistaken for pachymeningitis, 
because nerve-root symptoms are almost never 
prominent in the former. 
Traumatism of the Spine.-In those cases in which 
the symptoms resulting from traumatism are 
similar to those of tumor the history will show that 
the symptoms immediately followed injury, and 
will lead to a careful examination of the spine, 
showing marked tenderness over a considerable 
vertical extent. The tenderness is much greater 
than in tumor of the membranes or of the cord. 
The history would be the main reliance in differ- 
entiating injury of the bones from tumor of the 
same, except that in the former the spinal tender- 
ness involves a much greater vertical extent of the 
bones. It must be borne in mind that an injury 
of the spine may be followed by tumor; but under 
these circumstances there would be a history of two 
periods-the one immediately following the in- 
jury during which the symptoms will have been in- 
dicative of inflammation, and during the other there 
will have been a set of symptoms that mark the 
irritation caused by the beginning and development 
of the tumor. Traumatism of the cord in which 
nerve root and bone symptoms are absent would 
not easily be mistaken for tumor of the cord, as the 
acute symptoms of myelitis following trauma 
develop a few days after the receipt of the injury, 
and the patient is most conamonly paralyzed im- 
mediately after the accident. 
Neuritis affecting one nerve may occur from 
tumor. It may follow the development of tumor 
in the cervical region of the spinal canal, and affect 
one brachial plexus. Such a neuritis is due 
to pressure, and pressure neuritis in its early stage 
is not attended by tenderness over the trunk of the 
nerve, below the seat of the pressure, although 
pain is felt throughout the nerve and is most severe 
at its terminal end. Tenderness of the entire 
nerve does not take place until the neuritis descends 
the affected nerve. Spinal tenderness and pain 
in the spine on movement would probably be pres- 
ent in neuritis from pressure within the spinal 
canal. This would be absent in ordinary neuritis. 
Syringomyelia, in the majority of instances, is 
due to a gliosis, or a benign and slowly growing 
tumor of the central canal of the spinal cord. The 
symptoms are usually bilateral, the morbid process 
is spread over a large vertical extent of the cord, 
and the disease advances slowly, and often lasts 
many years. Dissociation of sensory symptoms is 
much more typical and pronounced than is the 
case in tumors of the cord. 
Location of the Tumor.-Is it in the vertebrae, 
cord, or membranes, and opposite what segment of 
the cord does it lie? Having satisfied one's self 
that a tumor exists, the next task is to locate it in 
some structure. 
Tumor of the vertebrae is attended by pain, out of 
all proportion in severity to that caused by tumor 
of the membranes or of the cord. The pain after 
the disease becomes well advanced is almost con- 
stant, even while the patient is lying quietly in bed. 
Movements of the spine greatly increase the pa- 
tient's suffering. Deformity of the spine, especially 
when the cervical region is the seat of the tumor, 
is not rare. Tenderness of the spine almost always 
exists, but in some cases it is not great unless severe 
pressure is made. There is marked rigidity of the 
back muscles, so that the spinal column is con- 
stantly fixed in such a position that jars are least 
likely to affect it. The nerve-root pains are severe, 
appear early, and last throughout the course of the 
disease, unless the affected nerves are completely 
destroyed. The nerve-root symptoms begin 
unilaterally, and the cord symptoms usually ap- 
pear before they become bilateral. 
Tumor of the cord usually manifests itself by 
unilateral symptoms. Nerve-root pains are absent, 
unless the tumor begins in one posterior horn, and 
affects the nerve-root fibers within the cord. Un- 
der such circumstances there will probably be 
some sensory disturbance below the tumor on the 
opposite side of the body. Cord symptoms begin 
unilaterally, unless the tumor is situated near the 
center of the cord. Bone, nerve-root, and menin- 
geal symptoms are usually absent in tumor of the 
cord. 
Tumor of the Meninges and Cauda.-1The most 
prominent symptom of tumor of the spinal canal, 
extramedullary in character, is unilateral pain 
affecting one or two nerves, unless the cauda is 
involved, in which case they are bilateral from 
the beginning and affect many nerves of both legs. 
Bone symptoms, except slight pain in the back, 
some rigidity of back muscles, and some tenderness 
over a limited portion of the spine are absent 
throughout; cord symptoms occur late, but these 
are likely to appear before the nerve-root pains 
become bilateral. 
After the tumor has been located in some struc- 
ture-bone, membranes, or cord-it is not diffi- 
cult to determine opposite what segment of the 
cord the highest portion of the tumor lies. The 
safe rule to follow is to ascertain the highest level 
of sensory disturbance-such as hyperesthesia or 
anesthesia-and locate the lesion about two spinous 
processes above this level. SPINAL CORD, TUMORS 
SPINE, CARIES 
What is the nature of the growth and is it op- 
erable? The history of syphilis, or evidences of 
constitutional infection, such as bone disease, an 
old iritis, the presence of sores in the mouth, or a 
tumor of the brain, would be in favor of the spinal 
tumor being syphilitic. This evidence would be 
strengthened by rapid development of symptoms. 
Scrofulous glands, or the presence of tubercles in 
the lungs, testes, or other portions of the body, 
would lead one to suspect that the spinal growth 
was tubercular in its nature. In the absence of 
syphilis or tuberculosis, tumor in the membranes 
of a child or young adult would probably be a 
fibroma or a sarcoma, and later in life a sarcoma 
or a carcinoma. The most common tumors of the 
cord are tubercular, gliomatous, syphilitic, and 
sarcomatous. In regard to whether the tumor is 
operable, this question cannot always be decided 
before making an exploratory incision. All 
tumors of the cord are inoperable-i. e., those 
that are strictly confined to the cord substance. 
Some slowly growing bone tumors are removable. 
In all cases of tumor of the vertebrae an effort 
should be made to remove the growth if the diag- 
nosis is made early, and it is fairly evident that the 
neoplasm is not malignant. Theoretically, all 
tumors of the membranes are operable, and in 
doubtful cases the patient should be given the 
benefit of the doubt, unless the contraindications 
to surgical procedure are too strong. 
Prognosis.-Syphilitic growths yield readily to 
proper medication. If treatment is instituted 
early and before irreparable damage has been 
done to the cord, a complete recovery may take 
place. In all other kinds of growths that are not 
operable the prognosis is unfavorable. Life may 
be preserved for several months, or even for years, 
in slowly growing neoplasms that are not malig- 
nant. 
Treatment.-Little space need be consumed in 
discussing the treatment of tumor of the spine, 
cord, or its membranes. In tumor of the menin- 
ges, unless it is quite evident that the neoplasm is 
not syphilitic, the patient should be placed on 
increasing doses of potassium iodid and inunctions 
of mercury pushed to the point of tolerance. In 
meningeal tumors, if the patient does not show the 
slightest improvement within 2 or 3 weeks, ex- 
ploratory operation is advised. In case the symp- 
toms grow steadily worse during this time, it is 
not safe to defer operating even for 2 or 3 weeks, 
as the structures of the spinal cord might be 
irreparably damaged before the expiration of 3 
weeks if the tumor is growing rapidly or other 
conditions suddenly develop that cause consider- 
able pressure on the cord. In inoperable tumors, 
if thorough antisyphilitic treatment for a period 
of 6 weeks is not attended by any improvement, it 
is not probable that further specific treatment will 
be followed by good results. Tubercular growths 
of the cord, membranes, or bones may be some- 
what benefited by small doses of potassium iodid, 
by cod-liver oil, arsenic, quinin, iron, and a full 
meat diet, together with rest in bed. In all cases 
of tumor of the vertebrae that are not amenable to 
internal medication, operative interference should 
be instituted before the cord is seriously affected, 
unless there is evidence that the neoplasm is 
malignant. In all inoperable tumors that will 
not respond to specific or tonic treatment the 
patient should be made as comfortable as possible 
by rest in bed, a generous diet, relief of pain by 
means of anodynes, preventing the formation of 
bed-sores, and by taking care of the bladder and 
bowels. 
SPINAL SCLEROSIS.-See Lateral Sclerosis 
(Primary). 
SPINAL SCLEROSIS, POSTERIOR.-See Loco- 
motor Ataxia. 
SPINE, CARIES (Pott's Disease; Tuberculous 
Spondylitis).-Inflammation of the vertebra is 
nearly always tubercular-in children, almost 
without exception-although it is not impossible 
that the immediate starting-point of the disease 
is some slight injury causing an extravasation of 
blood into the substance of the cancellous tissue. 
In exceptional cases it may be due to syphilis- 
perhaps more frequently than is suspected, in the 
case of adults-and late in life to rheumatism, 
osteoarthritis, and ostitis deformans. Tuber- 
cular ostitis is essentially a disease of childhood, 
although it may occur at any period of life. Some- 
times it is excited by injury, and usually affects 
but one part of the spine, though several vertebrae, 
etc., are involved together. 
Location.-Like tubercular ostitis elsewhere, 
it nearly always begins in the cancellous tissue, 
where growth is more rapid and the blood supply 
most abundant. The upper or under surface of 
the bodies of the anterior border is the-favorite 
seat; the spinous and transverse processes are 
almost never involved at the first, although later 
they become welded together as the inflammation 
extends to them; and the articular processes only 
when, as in disease of the atlas and axis, synovitis 
precedes ostitis. The most common situation is 
at the junction of the lumbar and thoracic regions; 
here the bodies are large, and strains are felt most 
severely. The cervical vertebrae enjoy much 
greater immunity; and the two highest-in chil- 
dren, at least-the greatest immunity of all. 
There is some reason to think that disease of the 
atlas and axis is proportionately more common in 
adults. Usually, the intervertebral discs are 
destroyed with the bones between w'hich they lie, 
the granulation tissue eating into them and caus- 
ing their gradual absorption. Sometimes they 
disappear at a very early period, as if the force of 
the disease was spent on them rather than on the 
bodies; very rarely they persist, as when the 
vertebrae are absorbed by the pressure of an 
aneurysm. 
The pathology does not present any special fea- 
ture. The disease begins as rarefying ostitis, the 
bone becoming softer, more open, and vascular, 
and the bone corpuscles undergoing fatty degenera- 
tion. According to the virulence and number of 
bacilli on the one hand, and the strength and 
resisting power of the tissues on the other, resolu- 
tion, caseation, or liquefaction follows. 
Disease of the upper two cervical vertebrae 
always commences as synovitis, and extends from SPINE, CARIES 
SPINE, CARIES 
the articulation to the bone beneath, spreading 
along the most vascular lines; and, therefore, if it 
involves the axis, separating the odontoid process 
from the body. 
The deformity depends upon the amount of 
destruction. If the caries is superficial, involving 
only the anterior surface of the body, and if repair 
begins at once, deformity may be entirely absent. 
If the bodies are softened or destroyed, even if 
only part of one, the spine sinks forward, the spin- 
ous processes project backward, and compensatory 
curves in the opposite direction are developed 
above and below. This is most distinct in the 
thoracic region; the lower cervical rarely becomes 
of its natural one. The deformity cannot, of 
course, remain limited to the spine. When the 
cervicothoracic region is affected, the chin is 
brought down on the sternum so that the move- 
ments of the neck cannot be carried out; and, 
similarly, when the curvature is lower down, 
the thorax is crushed together, respiration is 
carried out by the diaphragm only, and the heart 
and the abdominal viscera are placed at great 
disadvantage. 
Repair may commence at any time, the caseous 
material, if any has formed, and the debris being 
absorbed, dried up, or discharged externally. The 
vertebrae above and those below fall together; 
the spines, laminae, and, in the thoracic region, 
even the ribs become welded into a solid mass; the 
sinuses gradually close up; and bony splints are 
thrown out in proportion to the degree of strength 
required. 
Symptoms.-The most prominent symptoms are 
pain, rigidity of the back, peculiar posture, and a 
sense of weakness, which last, even when the child 
cannot describe it, can usually be recognized from 
the child's actions. 
Pain is rarely local; nearly always it is referred to 
the distribution of the spinal nerves, not to their 
origin; thus, in atloaxoid disease it is felt over the 
back of the head; or, when the thoracolumbar 
region is concerned, over the pubes. Sometimes 
there is a sense of constriction around the thorax, 
and children often describe it as stomachache. 
Usually, it is worse after standing or after any 
exertion; lying down, it may not be felt at all. 
As movement causes pain, the child will guard its 
spine against jarring by refraining from any 
violent or unusual action and the surgeon should 
not resort to jarring of the head and shoulders in 
the course of his examination. 
Muscular rigidity is highly characteristic; every 
movement of the segment of the back for some dis- 
tance above and below the seat of mischief is avoid- 
ed with the greatest care. If the cervical spine is 
involved, the whole trunk is turned around instead 
of the head when the patient wishes to look to one 
side, and it is done with the utmost deliberation. 
If it is the back, and the child is told to pick up 
anything from the floor, the hips and knees are 
bent, the head is thrown back, and the spine is 
kept absolutely rigid. Sometimes it voluntarily 
goes on hands and knees. For the same reason 
the walk is very peculiar, entirely different from 
the natural mobile gait, and wry-neck and other 
distortions are not infrequently present. When 
children are concerned, the weakness of the back 
must be judged of by their actions. They cease 
to play and run about; they wish to be let alone; 
and if they must stand, they try to support the 
weight of the head and shoulders by resting their 
hands upon the furniture, or even upon their knees, 
propping themselves up in a crouching.- attitude. 
With adults it is easier, as they can explain the 
peculiar difficulty they experience in holding 
themselves upright. 
Spinal Abscess (Psoas and Lumbar).-When 
suppuration occurs, the pus collects in front of the 
diseased vertebrae in the angle formed by the 
Ankylosis of Dorsal Vertebra with Great Deformity, 
Consequent on Caries of the Bodies.-(Moullin.') 
convex backward; only a little thickening is per- 
ceptible, and the lower lumbar practically is not so 
distorted. Disease between the axis and atlas is 
peculiar, again, in this; for, owing to the shape of 
the articulation on the former, the latter, when the 
ligaments are softened by inflammation, or when 
the odontoid process is detached from the base on 
which it rests, slips bodily forward, carrying the 
head with it, so that when the patient is viewed 
from one side, it appears as if the head were placed 
in front of the spine. The effect of this displace- 
ment (when it is below the third cervical vertebra) 
on the diameter of the spinal canal is exceedingly 
slight; often it is actually enlarged; exceptionally, 
a wedge-shaped portion is driven backward into 
the substance of the cord. When the upper two 
vertebrae, however, are concerned, the atlas slides 
forward and the anteroposterior measurement 
opposite the odontoid process may be reduced to 
less than 1/2 of an inch. This, if it is effected 
gradually, is not incompatible with life, and the 
odontoid process may even become ankylosed in 
its new situation as much as 1 /2 of an inch in front SPINE, CARIES 
SPINE, CARIES 
falling forward of the upper upon the lower portion 
of the spine. The anterior common ligament and 
the periosteum, relaxed by the bending of the spine, 
yield to the pressure of the pus, and, with the pleura 
or peritoneum, become thickened and form the 
abscess wall. The pus, prevented from traveling 
upward by the overhanging vertebrae, from travel- 
ing downward in front of the column by the attach- 
ments of the anterior common ligament, and from 
traveling backward by the posterior common 
ligament, and by the vertebrae being less diseased 
behind than in front, makes its way on one or 
the other side of the column. There it either 
enters the sheath of the psoas, and, destroying 
the contained muscle, presents in the iliac fossa 
or groin as an iliac or a psoas abscess, or it passes 
backward through or external to the quadratus 
lumborum, and points in the loin, when it is known 
as a lumbar abscess. In rare instances the pus may 
take a different course. Thus Walsham has seen 
it make its way into the ischiorectal fossa, or pass 
through the great sciatic foramen, or travel along 
the course of a rib and reach the surface near 
the sternum. Ocassionally an abscess forms on 
both sides of the spine at once. In the cervical 
region the abscess will point in the pharynx 
(retropharyngeal abscess) or in the neck. 
Spinal paralysis, like suppuration, may begin at 
any period, although naturally it is more common 
in the later stages of the disease. Loss of motion 
always precedes that of sensation, and may be 
nearly complete without the latter being seriously 
impaired. The gait becomes shuffling; the move- 
ments of one or more of the limbs are awkward; 
and the loss of power becomes more and more 
evident, with a certain degree of numbness, until 
at length complete paraplegia follows. As long 
as the cord is merely compressed, the patient may 
retain power over the rectum and bladder; but 
this, too, is not infrequently lost in the later stages. 
When myelitis sets in there is often severe pain 
along the course of the spinal nerves, with spas- 
modic muscular contraction; the skin becomes 
dry and branny; all power of the sphincters is 
lost; the limbs are wasted; the joints, generally 
speaking, are flexed; and the muscles are rigid and 
not infrequently thrown into violent spasmodic con- 
tractions from the uncontrolled reflex irritability 
of the spinal cord. Occasionally, the inflammation 
suddenly becomes acute, and extends upward, 
with symptoms of high fever, to the meninges 
of the brain. In disease of the cervical spine 
respiration may be seriously endangered either 
from displacement forward of the atlas and 
cranium upon the axis, or, when the disease is 
lower down, from gradual flattening of the cervical 
curve, owing to the softening of the ligaments. Un- 
der these circumstances any sudden movement of 
the head, either forward or backward, or even lying 
in the supine position without a support beneath 
the arch of the cervical spine, may cause immediate 
asphyxia. 
Diagnosis.-In the early stages caries must be 
differentiated from neuralgia, rheumatism, lum- 
bago, aneurysm, tumors, and hysteria; in the later 
stages the angular curvature may have to be 
distinguished from the kyphotic curvature of 
rickets. 
From neuralgia, rheumatism, and lumbago it is 
not always easy to distinguish it. The history 
of the former rheumatic attack, the effect of 
remedies, and the absence of the signs described, 
must then be relied upon. 
Hysteria may simulate it very closely. The 
absence of signs of caries, except pain; the in- 
constant and more diffused character of the 
pain; and the presence of other signs of hys- 
teria or of uterine disease, are the points to be 
attended to. 
A careful auscultation of the chest and exam- 
ination of the abdomen 
will usually serve to ex- 
clude aneurysm. 
From tumors of the 
vertebral bodies leading 
to the breaking down of 
the vertebrae caries cannot 
at first be differentiated, 
as both give rise to the 
same symptoms; but the 
age of the patient and 
the presence of a carcino- 
matous growth elsewhere 
would lead to suspicion 
of cancer. 
The curve of rickets is 
more generally kyphotic, 
and disappears com- 
pletely on gently holding 
the child up by its arms, 
or on extending it with 
its face downward across 
the nurse's knee. There 
are, moreover, concomi- 
tant signs of rickets, and 
absence of those of 
tubercle. 
Treatment.-The gen- 
eral principles are those 
of the treatment of tuber- 
culosis. With very few 
exceptions local removal 
of the diseased portion 
is out of the question; 
all that can be done is to 
improve the general 
health and to subdue the 
local inflammation, in the 
hope that the tissues may be able to cope success- 
fully with the disorder. 
Rest is the first consideration. In most cases it is 
advisable to confine the patient, for a time at 
least, to the recumbent position, on a well-made 
hair mattress, with sand bags as splints. In dis- 
ease of the upper cervical vertebrae rest is abso- 
lutely essential, a bag being placed on each side, 
coming well down against the shoulder, and a 
third smaller one under the arch of the spine. 
If the patient's condition is favorable, this may be 
kept up for many months without the least dete- 
rioration in health; indeed, distinct improvement is 
not uncommon, especially when the pain has pre- 
Double Thomas' Splint 
for Spinal Caries. SPINE, CARIES 
SPINE, CARIES 
viously been severe. Later, when the acute symp- 
toms have subsided the back may be incased in 
some kind of splint, and the patient allowed very 
gradually to begin to move about. To insure abso- 
lute recumbency Walsham uses a double Thomas' 
splint, modified by the addition of a pelvic band, 
a support for the shoulders, neck, and head, and 
two sliding foot-pieces. The two upright bars 
the bandages a folded towel should be placed 
over the abdomen beneath the vest, so that, when 
afterward withdrawn, space will be left for ab- 
dominal respiration (Sayre's stomach pad). When 
the plaster case is dry, it may be sawed through 
down the front, removed, and the fronts edged 
with leather and perforated with eyelet-holes, 
so that it can be worn laced up, and can be taken 
off from time to time. To apply the poroplastic 
felt, the jacket, which is first made to measure, 
must be put in a steam oven, and when rendered 
thoroughly plastic, further molded to the patient, 
who should be prepared and suspended in the 
same way as for applying plaster-of-Paris. Of 
steel instruments, that known as Taylor's is 
perhaps the best. When the disease is in the 
cervical or upper thoracic region, Sayre's jury- 
mast may be fitted to the plaster-of-Paris cast 
or poroplastic jacket; or a cervical collar com- 
posed of leather or poroplastic felt may be used; or, 
better, the combined poroplastic jacket and collar. 
The treatment of a tubercular abscess is either 
expectant or operative. Many of these are 
readily absorbed when proper mechanical support 
is afforded and the general health is improved. 
There are three indications for operative interfer- 
ence, viz: if the abscess is rapidly increasing in 
size, if it is interfering with the health of the 
patient, or if it is pointing, but unless one at least 
of these is present, a tubercular abscess should 
be left alone. Aspiration may be employed first to 
stay the progress of the abscess and possibly to 
remove it entirely. Force should not be used 
in aspirating, and it may be repeated frequently 
provided the trocar be inserted into healthy 
tissue each time. In these abscesses lavage of 
the sac with iodin water, followed by injection of 
iodoform emulsion, is of great benefit. The trocar 
and cannula used for evacuation should be large 
enough to prevent clogging during the outflow, 
and the puncture should be sealed with iodoform 
collodion laid on a thickness of gauze. 
In some cases in which necrosis has been asso- 
Saybe's Tripod. 
which are prolonged to the head support, are 
made after the shape of a normally formed child 
when in the recumbent position. 
The supports most in use at the present day 
are Sayre's plaster-of-Paris case and Cooking's 
poroplastic felt jacket, though some surgeons 
prefer steel instruments. The plaster-of-Paris 
case may be applied with the patient either in 
the upright position, suspended with his heels 
just off the ground by Sayre's tripod, or in the re- 
cumbent position, by 
Davy's hammock appara- 
tus. A skin-fitting vest 
having been previously 
applied, and a line drawn 
across the back with a 
pencil at the level of the 
axillae, to indicate the up- 
per limit of the jacket, 
crinoline bandages, im- 
pregnated with plaster-of- 
Paris, are wound round 
and round the trunk, until 
a sufficient thickness is 
obtained, dry plaster 
being from time to time 
rubbed in with the hand. 
The cast should reach 
from the pencil line to just below the crest of the 
ilium, stopping short of the great trochanter 
and the pubes, and may be strengthened, if neces- 
sary, in places by inserting strips of perforated tin 
vertically between the bandages. Before applying 
Head Extension for Pott's Disease.-{Young.) 
ciated with caries success has attended the re- 
moval of the sequestrum through a properly planned 
incision made in the loin. In exceptional cases, 
in which the paralysis of the lower limbs continues 
in spite of absolute rest and recumbency, and in SPINE, CURVATURE 
SPINE, CURVATURE 
which there is intractable cystitis or severe pain 
not relieved by ordinary measures, the spines and 
laminae of the affected vertebrae may be excised 
for the purpose of relieving pressure on the cord. 
The compression of the cord, however, would ap- 
pear to depend more often on the presence of a 
tuberculous collection in front of or about the cord 
than on displacement of bone. 
Unless, therefore, the tuberculous abscess can 
be evacuated, the removal of the arches of the 
vertebrae is futile, and only tends to weaken the 
vertebral column. In place of laminectomy an 
attempt may, in suitable cases, be made to reach 
the tuberculous collection from the front of the 
vertebrae. M6nard has succeeded in doing this 
by excising the transverse processes and proxi- 
mal ends of the ribs corresponding to the most 
prominent part of the spinal curve. Through the 
aperture thus made he was able to scrape 
and wash away tuberculous material, with the 
result that the paralysis quickly disappeared 
(Walsham). 
Hibbs' Osteoplastic Operation.-This operation, 
which has now been performed in about 200 cases, 
has been eminently successful. It is performed as 
follows: A longitudinal incision is made directly 
over the spinous processes, through skin, supra- 
spi ous ligament and periosteum to the tips of the 
spinous processes. The periosteum is split over 
both the upper and lower borders of the spinous 
processes and the laminae, and stripped back from 
them to the base of the transverse processes. The 
spinous processes are then transposed after partial 
fracture, so that they make contact with fresh 
bone, the base of each with its own base, and the 
tips with the base of the next below. The adjacent 
edges of the laminae being absolutely free from peri- 
osteum, a small piece of bone is elevated from the 
edge of the laminae and placed across the space be- 
tween them, its free end in contact with the bare 
bone of the lamina next below it. The lateral 
walls of periosteum and the split supraspinous 
ligament are brought together over these processes 
by interrupted chromic catgut sutures. The skin 
wound is closed by silk, and a steel brace applied. 
SPINE, CURVATURE.-The spine may become 
curved, either from primary disease of the bones 
and joints (caries, osteoarthritis, new growths, 
etc.), or from weakness of the muscles whose 
function it is to maintain the erect position, the 
vertebrae only becoming affected secondarily 
after the deformity has already lasted some time, 
owing to the unequal distribution of the weight 
they bear. The direction may be either antero- 
posterior or lateral, although the latter rarely 
occurs by itself. The former is known as excurva- 
tion, or kyphosis, when the projection is convex 
backward; as incurvation, or lordosis, when it is 
convex forward. The lateral bending is known 
as scoliosis. 
curves are rotated on their vertical axes so that 
the spinous processes are directed toward the con- 
cavity of the curves. 
Etiology.-The immediate cause that underlies 
the formation of lateral curvature is the unequal 
compression of the intervertebral cartilages for 
long periods. This 
unequal compression 
may be induced (1) 
by any condition caus- 
ing permanent or ha- 
bitual obliquity of the 
pelvis and the conse- 
quent throwing of the 
spine over to the op- 
posite side, such as 
unequal length of the 
legs, knock-knee, flat- 
foot, the use of a 
wooden leg, habit of 
standing on one leg, 
sitting cross-legged, 
congenital dislocation 
of the hip, etc.; (2) by 
a one-sided position 
of the body in sitting, 
standing, or lying, or 
produced by certain employments, as nursing 
or carrying with one arm, etc.; (3) by contraction 
of one side of the chest following empyema; (4) 
by unilateral contraction of the spinal muscles 
following paralysis of the opposing muscles. The 
conditions mentioned under 1 and 2 are, however, 
by far the most frequent causes of the deformity. 
Although lateral curvature may be induced by 
these causes acting alone, there are certain circum- 
stances that appear especially to predispose to the 
deformity, by producing a general want of tone in 
the muscles, and structural weakness of the liga- 
ments and bones. Such are (1) heredity, (2) gen- 
eral debility, (3) the strumous diathesis, (4) 
rickets, and (5) rapid growth. It is much more 
frequently met in girls than in boys, and is most 
common from about the age of 14 to 18 (Walsham). 
Pathology.-The long-continued unequal com- 
pression of the intervertebral cartilages causes 
them to become wedge-shaped, and the portion of 
the spine corresponding to the compressed carti- 
lages to assume sooner or later a permanent lateral 
curve. While, however, a curve is thus being pro- 
duced, say, in the thoracic region, with its convex- 
ity to the right, a compensating curve, in order to 
maintain the equilibrium of the spine, is being 
simultaneously produced in the lumbar region 
with its convexity to the left. Coincidently with 
these changes a rotatory movement of the affected 
vertebrae upon their vertical axes is taking place; 
so that while the bodies turn toward the convexity 
of the curve, the apices of the spinous processes 
turn toward the concavity. Hence, in addition to 
the formation of the primary and the secondary 
or compensating curves, we have a twisting round 
of the spine within these curves, as a consequence 
of which the ribs on the convex side are carried 
backward with the transverse processes, causing 
the angle of the scapula on that side to project; 
Extreme Scoliosis.-(Moullin ) 
Scoliosis. 
Scoliosis, or lateral curvature, is a complicated 
distortion in which the spine forms two or more 
lateral curves, with their convexities in opposite 
directions, while the vertebrae involved in the SPINE, CURVATURE 
SPINE, CURVATURE 
while the ribs on the concave side are for the same 
reason carried forward, producing a prominence 
of the corresponding breast (as shown in the 
accompanying illustration). 
depression between it and the ribs. On the left, 
the outline of the body is nearly straight. Seen 
from the side, the head projects forward, the 
thorax is flat, half concealed by the shoulders, and 
the lower part of the abdomen projects, owing to the 
anteroposterior bend that, when the muscles are 
weak, nearly always complicates the lateral one. 
In front, the left breast stands out more than the 
other, and the asymmetry of the thorax is even 
more distinct. Next, the patient is directed to 
stoop forward, the knees being kept straight, the 
head bent down, and the arms hanging loosely in 
front. This gives an idea of the amount of 
rotation. The ribs posteriorly are uncovered, 
and the projections backward of the lower part 
of the chest on one side, and of the erector spinse 
in the lumbar region on the other, are brought 
prominently into view. It is often of service to 
keep a record of this position by molding a malle- 
able piece of lead (as suggested by Roth) trans- 
versely to the ribs, between the angle of the 
scapulae, and taking a tracing from this on paper. 
If the deformity is conspicuous, a second tracing 
may be taken opposite the third lumbar spine. 
Afterward the patient is directed to straighten 
her back by her own unaided efforts; and if, as is 
probable, this merely results in increasing the de- 
formity, an attempt must be made, by manipulat- 
ing the trunk and the limbs, to see how far it is 
possible for the muscles to restore the symmetry. 
In cases in which there is no osseous deformity this 
can usually be done by placing the patient in what 
Roth has called the key-note position, with the 
right arm directed upward, and the left one at 
right angles to the trunk. 
The prognosis depends chiefly upon the state of 
the vertebrae. If they are not yet affected, the 
patient can generally be cured, if she will take 
sufficient trouble, although relapses are almost sure 
to occur from time to time until the development 
of the trunk is complete. If, on the other hand, 
osseous deformity is already present, neither rota- 
tion nor curvature can be corrected, except in 
very early cases; and when there is evidence of 
recent rickets, all that can be done is to prevent 
them from becoming worse. 
Treatment.-When there is evidence of general 
or muscular debility, the health and muscular tone 
should be improved by suitable remedies, the 
avoidance of late hours, of fatigue, and the like; 
the exciting cause of the curvature should be 
looked for and, if possible, removed. In slight 
cases these means, when conjoined with a judi- 
cious selection of muscular exercises and partial 
recumbency, will generally serve to cure or to im- 
prove the curvature, or, at least, will prevent it 
from getting worse. But in severe cases, when 
osseous changes are already confirmed, some form 
of rigid support, as a poroplastic jacket or a light 
spinal instrument, will commonly be required, 
especially for the poorer classes of patients. In 
ordering such supports, however, the patient 
should be made to understand thoroughly that no 
real impi'ovement of the curvature must be expect- 
ed from them, their only aim being to relieve pain 
when present, to give a sense of comfort and sup- 
To Show the Effect of Rotation in Lateral Curva- 
ture of the Spine.-(Walsham.) 
Symptoms.-Pain or a feeling of weakness in the 
back, general lassitude, and a stooping gait are 
among the early symptoms; but the patient is 
generally first brought for consultation on account 
of a slight projection of the scapula, or of an appar- 
ent prominence of the iliac crest-a growing out 
of the shoulder or of the hip, as it is popularly 
termed. In mild cases there may be little or no 
lateral deviation of the apices of the spinous pro- 
cesses, and that present may be made to disappear 
on suspending the patient or on placing her in the 
prone position. In the severer cases, however, 
the signs are unmistakable. Thus, in the more 
common forms there are usually a thoracic curve, 
with its convexity to the right, and a shorter lum- 
bar or thoracolumbar curve, with its convexity 
to the left. The right shoulder is generally ele- 
vated, and the angle of the right scapula, right 
iliac crest, and left breast are prominent, while 
the left lumbar muscles, in consequence of the 
backward projection of the left lumbar trans- 
verse processes, stand out as a prominent ridge 
and give a greater sense of resistance on pressing 
over them than normal. In other cases the com- 
pensating curves may be so slight that there is 
apparently a single curve only, with its convexity 
either to the right or left, involving the whole 
spine or chiefly the upper thoracic or the lumbar 
vertebrae, and producing more or less projection 
of the scapula or apparent prominence of the 
iliac crest, etc., according to its severity and situa- 
tion. 
Method of Examination.-The clothing is so 
arranged that the body above the iliac crests and 
the gluteal cleft can be inspected from all sides. 
If, from the height of the crests, there is any 
reason to suspect inequality of the lower limbs, 
this must be investigated first, and compensation 
made by placing a book under the shorter leg. 
At first the patient stands upright, with the feet 
together, in a natural, unconstrained position. 
If the muscles are rigid and contracted, so that 
the attitude is stiff, they nearly always give way 
in a minute or two. In the meantime the tip of 
each spinous process is marked with an anilin 
pencil. In an ordinary case, with the dorsal 
convexity on the right, the scapula on that side 
is higher and more prominent, the chest fuller, 
and the iliac crest better marked, with a deep SPINE, CURVATURE 
SPINE, INJURIES 
port, to improve the outward appearance, and to 
prevent further deformity. In slight cases they 
should on no account be used. The exercises 
employed are directed in part to improving the 
muscular tone generally, and in part to strengthen- 
ing those muscles in particular that tend to lessen 
or straighten the curves. For the former purpose, 
such exercises as swinging by the hands from a 
bar, forcibly stretching an elastic cord fixed to the 
floor, and dumb-bell exercises should be practised. 
For strengthening the muscles in particular that 
tend to straighten the curve, the back should be 
manipulated until that posture is found in which 
the curves are least marked, and the patient should 
be made to hold herself in this position as long as 
possible. At first she will be only able to do this 
for a few minutes at a time; but by frequently 
assuming the posture the muscles thus brought 
into play are gradually strengthened, until at last 
the improved posture is maintained constantly 
and without effort. For further improving the 
tone of these muscles, Busch and Roth recom- 
mend exercises similar to the followng: The 
patient's body, held in the improved posture, 
is brought over the end of a couch or table, 
and while she is prevented from falling by an 
assistant holding her legs, she alternately flexes 
and extends her body at the hips, the surgeon 
resisting her efforts. Some surgeons use the 
sloping seat, as recommended by M. Bouvier 
and Mr. Barwell, in counteracting the curves. 
A similar effect may be obtained by wearing a thick 
sole on one boot, and by sitting on the off side of 
the horse when riding. After the exercises, or 
twice or thrice during the day, the patient should 
lie on her back for from half an hour to an hour; 
and while sitting, her back should be supported by 
a reclining chair. Walsham has had considerable 
success in removing rigidity in cases where there is 
slight osseous deformity by applying a weight to the 
convexity of the curve, the patient standing with 
her legs straight and body horizontal, and being 
supported in this position by her elbows on a 
chair. 
caries, is rigid, and the child is uneasy in this 
position and tries to resist the extension by 
muscular effort, and draws up his legs. In 
rickets the back is flexible and there are other 
signs of rickets. 
Treatment.-In the infant, recumbency; in 
growing lads and girls, the correction of stooping 
habits by the use of muscular exercises and a 
spinal brace, with partial recumbency and tonics, 
is the treatment usually indicated. For the con- 
firmed kyphosis of the old, nothing can be done. 
Lordosis. 
Lordosis, or curving of the spine with the con- 
vexity forward, is a symptom rather than a 
disease, inasmuch as it is formed as a compensa- 
tory curve to restore the equilibrium of the 
spine when from any cause its normal antero- 
posterior curves are disturbed. Thus, it is most 
common in the lumbar region, where it is merely 
an exaggeration of the normal curve, and is 
there produced to counterbalance the tilting 
forward of the pelvis consequent upon hip-dis- 
ease, congenital distortion of the hips, rickets, etc. 
SPINE, DISEASES.-See Spine (Caries, Curva- 
ture), Spondylitis Deformans. 
SPINE, INJURIES.-Sprains of the spine are 
exceedingly common, and may be caused by any 
violent twist or bend of the back. See Back 
(Injuries). 
Dislocation and Fracture.-Dislocation of the 
spine without fracture is extremely rare; indeed, 
except in the cervical region, it is said never to 
occur. Fracture unaccompanied by dislocation 
is also uncommon; but uncomplicated cases of 
fracture of the spinous process and laminae, 
and, more rarely, of the transverse and articular 
processes, are sometimes met with. In the 
majority of cases fracture and dislocation are 
combined. Thus, usually there is fracture of the 
body and of the articular processes of one or more 
vertebrae, with dislocation of the whole of the 
spine above the seat of injury from the spine 
below. This common form of injury is known 
as fracture-dislocation. 
Fracture-dislocation is either the result of 
direct violence applied to the spine, or of indirect 
violence, as a fall upon tne head. 
When the result of direct violence, which can 
only be applied to the posterior part of the spine- 
one or more of the spinous processes may be de- 
tached without implicating the vertebral canal. 
When the violence is very great-as in a fall from 
a height on the back across a beam or rail, or as 
the result of a severe blow, as from a crane-the 
spine is bent violently backward, tearing asunder 
the structures forming the anterior segment of the 
column and crushing those forming the posterior 
segment. Hence the vertebral bodies are generally 
uninjured, but are wrenched apart, the inter- 
vertebral cartilages are ruptured, the anterior 
common ligament is torn, and the arches of the 
vertebrae and of the articular and spinous proc- 
esses are crushed. The vertebrae above the 
injury are dislocated forward, as, the articular 
processes being fractured and the intervertebral 
Kyphosis is a general curving of the spine with 
its convexity backward or an exaggerated condi- 
tion of the normal dorsal curve. It depends 
upon an unequal compression of the interverte- 
bral cartilages and, to a less extent, of the verte- 
bral bodies, which thus become wedge-shaped, 
with their bases looking posteriorly. It is gen- 
erally the result of muscular debility, rickets, 
slouching habits, or occupations necessitating 
stooping. 
Symptoms and Diagnosis.-The chief point of 
interest is to distinguish it from the serious 
angular curvature induced by caries. In children 
and in adults this is generally easy; but in rickety 
infants, in whom the ordinary test for caries can- 
not be applied, it is often very difficult. In such 
a case the infant should be placed across the 
nurse's knees and gently extended, when the 
rickety curve will disappear, but the angular 
curve will remain. The back, moreover, in 
Kyphosis. SPINE, INJURIES 
SPINE, INJURIES 
cartilages torn, nothing remains to keep them in 
position. 
In fracture from indirect violence-such as may 
be received in a fall from a height upon the head, or 
catching the head while passing under an arch, or 
from a weight falling upon the head or shoulders- 
the spine is bent violently forward, crushing the 
anterior part of the column and tearing the poster- 
ior part asunder. Here one or more of the bodies 
and intervertebral cartilages are crushed between 
the vertebrae above and the vertebrae below, one 
of the fragments of the fractured body being fre- 
quently driven backward into the vertebral canal, 
while the arches and the spinous and articular 
processes are wrenched asunder. Fracture of the 
of injury (paraplegia), and perhaps a zone of 
hyperesthesia immediately above the injured part. 
The intercostal muscles being paralyzed, respira- 
tion can only be carried on by the diaphragm, 
this muscle receiving its nerve supply through the 
phrenics that are given off above the seat of injury. 
Hence, while the chest is motionless, the abdomen 
rises and falls during respiration. The bladder 
and rectum and their respective sphincters share 
in the paralysis, so that there is at first retention of 
urine and of feces, followed by passive overflow of 
urine as the bladder becomes distended and will 
hold no more, and by involuntary passage of feces. 
Priapism, or involuntary erection of the penis, is 
frequently present, or is induced by the use of the 
catheter. The temperature varies: sometimes it 
may be lower than the normal, but often it is 
considerably elevated, even reaching as high as 
107° F. shortly before death. Consciousness, 
unless any head injury has been received at the 
same time, is not affected. The reflexes in the 
lower limbs are usually at first in abeyance, but 
may return if the patient does not succumb to 
the shock of the injury. If the reflexes remain 
quite lost, the probabilities are that the conducting 
power of the cord has been completely destroyed. 
If they return, it is a sign that some power of 
conductivity is left in certain portions of the cord 
at the seat of injury. Death occurs, as a rule, 
in from 24 hours to a few days, from bronchial 
trouble; but the patient, if the fracture is in the 
upper thoracic region, may linger from 2 to 3 
weeks. The secondary troubles that are then 
generally met with are bed-sores and chronic 
cystitis, probably due in part to impaired nerve 
influence, and in part to slight injury in the pas- 
sage of a catheter, or to the introduction by the 
catheter of a microorganism-the micrococcus 
ureae. 
Such may be taken as a typical example of 
fracture of the spine as commonly met with in 
surgical practice. But the nature and gravity 
of the symptoms will depend upon the situation 
of the fracture, and upon the amount of injury 
to the cord. Thus, in some cases of fracture 
there may be no paralysis; in others, the paralysis 
may be incomplete: i. e., confined to loss of motion 
only, or to paralysis of one limb or one group 
of muscles, or to impairment of sensation over 
some limited area. Such cases, however, are 
much less common than that previously described 
(Walsham). The X-rays should always be em- 
ployed when possible, to determine the extent and 
character of the injury to the bony parts. 
The prognosis will depend in great measure on 
the situation of the fracture and on the condition 
of the cord. Thus, when the fracture is in the 
cervical region, if death is not instantaneous, the 
patient may survive from 12 hours to 2 or 3 days; 
usually, however, death occurs in about 24 hours; 
when in the upper thoracic region, the patient 
may linger for 2 or 3 weeks; when in the lower 
thoracic region, if he survives the period at which 
the inflammatory troubles commonly occur, he 
may recover, remaining, however, if the cord is 
severely injured, paraplegic; when in the lumbar 
Diagram of Fracture-dislocation of the Spine, show- 
ing compressions of the cord by the laminse of the 9th dorsal 
vertebra (A), and by the body of the 10th dorsal vertebra 
(B). C. Spines in same case as felt from the rear. 
sternum is occasionally combined -with this injury, 
in consequence, it is said, of the chin coming into 
violent contact with the sternum as the spine is 
doubled forward. 
Condition of the Spinal Cord.-The importance 
of fracture-dislocation of the spine lies not so much 
in the fact that the vertebrae are fractured, as that 
the cord is generally injured. When the vertebrae 
are not displaced, the cord may at times altogether 
escape. More commonly, however, it is compress- 
ed; or, perhaps, completely divided; or, again, so 
bruised that it rapidly undergoes inflammatory 
softening. When the injury is situated below 
the second lumbar vertebra, the cord necessarily 
escapes, as it terminates at that spot; but the 
nerves of the cauda equina may then be injured. 
Symptoms.-The local signs are often but little 
marked. There may be pain at the seat of injury, 
or some inequality in the spinous processes; but 
as often as not these are absent. The general signs 
depend upon the condition of the cord, and none 
will be present when it has escaped injury. But 
when it is compressed or crushed, there will be 
paralysis of the parts below, more or less complete 
according to the extent of the lesion. Taking as 
an example a case of fracture in the lower cervical 
or upper thoracic region, the most common situa- 
tion, with severe compression or crushing of the 
cord, there will be paralysis of both motion and 
sensation of the whole of the parts below the seat SPINE, INJURIES 
SPLEEN, DISEASES 
region, he may recover, with perhaps only partial 
paralysis of one or other of the lower limbs or of a 
certain group of muscles, or even without any 
paralysis whatever. But even when the injury 
to the cord has been so high as to cause paralysis 
of the whole body below the neck, patients have 
been known, in rare instances, to live for several 
months, or even for years. 
Treatment.-In cases in which there is no paral- 
ysis, thus showing that the cord is not affected, the 
indication is to keep the fractured spine at perfect 
rest, for the purpose not only of obtaining union 
of the fracture, but also of preventing by any 
movement displacement of the fragments and 
injury of the cord. In the more common cases, 
when there is paralysis, showing that the cord is 
injured, the indications are to remove any frag- 
ments that may be compressing the cord, and 
subsequently to keep the parts at rest until union 
of the bones has occurred. When, however, as is 
too frequently the case, the removal of the frag- 
ments is not practicable, or the cord itself has 
been crushed, all that can be done is to endeavor to 
guard against the formation of bed-sores and the 
occurrence of chronic cystitis and its attendant 
evils. Thus, the patient should be placed upon a 
water-bed, and his posture gently changed from 
time to time, so that pressure may not be con- 
tinuously made on one part, while he must be kept 
scrupulously clean and dry, and free from urine 
and feces. The bowels should be cleared, if neces- 
sary, by enema, or excessive diarrhea controlled 
by morphin suppositories or by starch and opium 
injections. Should bed-sores threaten, the skin 
should be hardened by sponging with rectified 
spirit, and dusted with oxid of zinc and starch- 
powder. If formed, they should be dressed with 
mild antiseptics, iodoform, balsam of Peru, 
etc., and all pressure removed from the surround- 
ing skin by the use of water-cushions. To prevent 
cystitis from occurring, a soft-rubber catheter, 
thoroughly cleansed in carbolic acid and dipped 
in carbolic oil, should be passed twice daily. 
Should the urine become alkaline, the bladder 
must be washed out with some antiseptic solution, 
as salol (10 grains to 1 ounce) or boric acid (10 
grains to 1 ounce). 
Extension of the Spine.-In cases in which, from 
the marked inequality of the spinous process, there 
is a probability of fragments pressing upon the 
cord, a cautious attempt to extend the spine and 
to reduce the displaced vertebrae may be made, 
and a plaster-of-Paris case may be applied during 
the extension. 
Laminectomy is the operation of removing the 
posterior vertebral arches. It is performed for 
the purpose of relieving pressure on the vertebral 
cord, but is contraindicated when it is likely that 
disorganization of the cord has been effected. 
An incision is made down the vertebral spines of 
the patient, who lies prone, with a firm sand-pillow 
under the lower ribs. The spinous processes and 
the laminae are cleared, and the periosteum is 
incised and lifted away from the arch. Forceps 
remove the spinous processes close to their bases, 
and the laminae are cut off on each side by rongeur 
forceps, exposing the dura mater. Fragments 
may be found exposing the vertebrae, and a blood- 
clot may exist between the dura and the bone. 
The dura may be incised and the clot removed, 
or the dura may be closed with catgut, the wound 
drained throughout by a tube, the superficial parts 
being closed with silkworm-gut, and antiseptic 
dressings applied. In operating, hammers and 
chisels should not be used, on account of the jarring 
to the structures. 
SPINE, TUMORS. See Spinal Cord (Tumors). 
SPIRILLUM FEVER.-See Relapsing Fever. 
SPIRITS.-Alcoholic solutions of volatile sub- 
stances, which may be solids, liquids or gases. 
They are officially prepared either by simple 
solution, by solution with maceration, by gaseous 
solution, by chemical reaction, or by distillation. 
The menstruum is alcohol in nearly all instances, 
4 having water in addition, and 2 being alcoholic 
liquors of a specified alcoholic strength (whisky, 
brandy). The official spirits are 20 in number; 
those made from volatile oils are frequently called 
essences. 
Spiritus aetheris (32 1/2); S. aetheris compositus 
(32 1/2); S. aetheris nitrosi (4); S. ammoniae (10); 
S. ammoniae aromaticus (9); S. amygdalae amarae 
(1); S. anisi (10); S. aurantii compositus (20); S. 
camphorae (10); S. chloroform! (6); S. cinnamomi 
(10); S. frumenti (37 to 47 1/2); S. gaultheriae (5); 
S. glycerylis nitratis (1); S. juniperi (5); S. juniperi 
compositus (64 1/2); S. lavandulae (5); S. menthae 
piperi tae (10); S. menthae viridis (10); S. vini gallici 
(39 to 47). The figures placed after spiritus fru- 
menti, spiritus juniperi comp., and spiritus vini 
gallici, represent the percentage of absolute alcohol 
by weight in each; those placed after the others 
indicate the quantity of the principal ingredient 
in grammes to each 100 cubic centimeters of the 
preparation. 
SPIROSAL.-The monoglycol ester of salicylic 
acid. It is an efficient external remedy in rheu- 
matic affections. When rubbed into the skin, it 
is nonirritant and readily absorbed, and it 
liberates salicylic acid in the tissues. 
SPLEEN, DISEASES. Physical Examination.- 
The spleen lies in the left hypochondriac region, 
the internal or concave surface being in close 
relation with the greater curvature of the stomach 
and tail of the pancreas; the upper border lying 
immediately under the diaphragm; the lower 
border covers the left suprarenal capsule and a 
small portion of the kidney, to which it is attached 
by areolar tissue. It extends transversely from 
the upper border of the ninth to the lower border 
of the eleventh ribs, and anteriorly to the mid- 
axillary line. The patient is placed in the re- 
cumbent posture. By inspection, enlargement 
of the organ is detected. 
Palpation confirms inspection, detects tender- 
ness, position and character of enlargement, 
whether hard or soft. In the normal condition 
the organ does not admit of palpation. The spleen 
is said to be enlarged when the anterior surface 
can be felt at the free margin of the ribs on deep 
inspiration, or if it projects beyond the mid- 
axillary line on percussion. SPLENECTOMY 
Percussion.-The patient is placed in the re- 
cumbent position on the right side, with the thighs 
flexed. Deep percussion is necessary, and should 
begin in the midaxillary region over the lung, 
gradually going downward in order to detect 
impaired resonance over a more dense medium. 
Dulness is usually elicited at the upper border of 
the ninth rib, and extends downward to the lower 
border of the eleventh rib, when tympany exists 
over the region of the intestine. The anterior 
border is determined by first percussing over the 
bowel, gradually moving toward the splenic 
dulness, which is found in health in the mid- 
axillary line. If it projects beyond the mid- 
axillary line, the organ is said to be enlarged. 
Morbid conditions of the spleen arise as the 
result of some general disease, such as malaria, 
leukemia, syphilis, or by extension of some 
inflammatory process from a neighboring organ. 
Splenitis.-This may be the result of traumatism 
or extension of a septic process from the stomach, 
perinephritic abscess, or disease of the diaphragm. 
It is recognized by enlargement and tenderness 
of the organ. 
Perisplenitis may be due to extension of in- 
flammation from adjacent tissues or from trau- 
matism. The resulting adhesions cause pain 
during respiration. There may be palpable 
crepitus over the spleen. 
Treatment.-Relief may be obtained by counter- 
irritant and 10 percent iodin inunctions. 
Splenic abscess occurs occasionally during the 
course of pyemia. It may break into the stomach, 
intestines, lungs or peritoneal cavity. 
Rupture of the spleen is caused by traumatism or 
pernicious malarial fever. In this condition there 
is a sudden sharp pain in the region of the spleen, 
accompanied by evident symptoms of collapse. 
Tumors of the Spleen.-The spleen may be the 
seat of gummatous tumors, or of an echinococcus 
cyst. 
Amyloid spleen occurs as the result of prolonged 
suppurative process, as in tubercular bone-disease, 
and may be associated with amyloid liver and 
kidney. 
Echinococcus of the Spleen is associated with 
similar infection elsewhere. The characteristic 
booklets may be recognized in the aspirated fluid. 
The spleen presents a fluctuating tumor which is 
distinguished from abscess by the absence of symp- 
toms of sepsis (chills, fevers, etc.) Echinococcus 
disease may, however, take on a purulent form. 
Movable spleen is due to elongation of the gastro- 
splenic ligament and blood-vessels. 
Symptoms.-Absence of the normal splenic 
dulness, the presence of a movable hard tumor in 
the lumbar or epigastric regions, accompanied by 
a dull, dragging sensation in the affected parts 
may distinguish the condition. 
Treatment consists in the application of a pad 
and an abdominal binder. Prolonged rest in bed 
is necessary to obtain relief. 
SPLENECTOMY.-Splenectomy, or extirpation 
of the spleen, may be required for rupture of the 
viscus, and for some forms of enlargement and 
tumors. It should not be proceeded with if on 
exposure extensive adhesions are found, since, un- 
less all these can be securely ligatured, fatal recur- 
rent hemorrhage is almost certain to take place. 
An incision is made either in the left linea semi- 
lunaris, or still further to the left, and the spleen 
having been thoroughly exposed, each adhesion 
carefully tied, and the organ, if enlarged, drawn out 
of the wound, the pedicle is then transfixed in sev- 
eral places with strong silk, and the ligatures inter- 
locked and tied. The pedicle is next severed well 
to the splenic side of the ligatures, the organ re- 
moved, the peritoneum thoroughly cleansed, and 
the abdominal wound united without or with 
drainage. Great care should be taken not to tear 
the splenic substance, an accident attended with 
fearful hemorrhage (Spencer and Gask). 
SPLENIC ANEMIA. (Splenic Pseudoleukemia).- 
A chronic anemia characterized by progressive 
hypertrophy of the spleen, without the glandular 
enlargement of Hodgkin's disease. 
The etiology is unknown, but infectious diseases 
and intestinal infection are believed to be factors. 
The symptoms and blood changes are similar 
to those of pernicious anemia. These include 
pallor, dyspnea, palpitation, progressive weakness, 
enlarged spleen; and later, emaciation, deeper 
yellow hue of the skin, tendency to hemorrhages, 
fever, serous effusions, diarrhea. The red blood 
cells are diminished. The hemoglobin percentage 
is lowered, but is relatively less than the corpuscles. 
Later in the disease there is ascites due to cirrhosis 
of the liver (Banti's disease, q. v.). The disease is 
a protracted one. 
Treatment.-Nutritious food, arsenic, iron and 
bone-marrow are indicated as in other anemias. 
About 75 percent of recoveries are reported to 
have followed splenectomy. This operation is 
contraindicated in profound cachexia. Talma's 
operation has also been performed in few cases. 
SPLENIC EXTRACT.-The substance of the 
spleen has been recommended in malaria, tuber- 
culosis, typhoid fever, and in various disorders of 
the blood. The ethereal extract, in the form of 
an emulsion containing 5 grains to the dram, is 
the most active preparation. It is given in daily 
doses up to 4 drams. 
SPLENOMEGALY, TROPICAL.-See Kala-azar 
SPONDYLITIS (Tuberculous).-Acute osteo- 
myelitis of the spine. A rare infection due to the 
same causes as osteomyelitis elsewhere. (See 
under Bone, Diseases.) It is too diffuse and rapid 
for successful surgical treatment. See Spine 
(Caries). 
SPONDYLITIS DEFORMANS.--A form of ar- 
thritis deformans characterized by a striking ri- 
gidity of the spinal column. If not associated with 
kyphosis it has been called "poker back." It 
may be accompanied by osteoarthritic changes in 
the shoulder and hip (Spondylose rhizomelique). 
SPONDYLOLISTHESIS.-A slipping forward 
of the lumbar upon the sacral vertebrae. 
SPONDYLOSE RHIZOMELIQUE.-Ankylosis 
of hip, spine and shoulders, occurring chiefly in 
old men. See Spondylitis Deformans. 
SPONGES.-Marine sponges are especially used 
in operations on the throat and abdomen-in the 
SPONGES SPOROTRICHOSIS 
SPRAINS 
former because mucus adheres, in the latter 
because the omentum and intestines do not adhere 
to marine sponges, whereas the reverse is the case 
with those made of wool or gauze. Owing to the 
difficulty in preparing and cleaning them, they 
are not generally used except as above. Marine 
sponges must first be freed from sand and remains 
of marine organisms by prolonged soaking and 
kneading in water. Then they are covered for a 
day with sulphurous acid 20 percent or 1 in 5, 
alternatively with hydrochloric acid 8 percent, or 
with permanganate of potassium 1 in 400, followed 
by saturated oxalic-acid solution to decolorize. 
After all acid has been washed away the sponges 
are placed in a jar covered with 1 in 20 carbolic acid, 
where they should remain at least a day before 
use. They may be so preserved indefinitely, 
merely becoming browner, or the sponges may be 
counted into linen bags, which are tied, labelled, 
and then hung up to dry in the air. Such sponges 
are then ready for use at any time with sterile 
water. After use, sponges must not be put straight 
into carbolic acid, but must soak in warm water 
und be kneaded at intervals for a day or more 
antil all the fibrin of the blood has become dis- 
solved, which it will soon do, unless it has been 
coagulated by heat or by carbolic acid. When 
the water in which the sponges are being kneaded 
remains clear, the sponges are treated with sul- 
phurous acid followed by carbolic acid as above 
described. But all sponges which have come in 
contact with infective material should be burnt. 
(Spencer and Gask.) 
SPOROTRICHOSIS.-A subacute or chronic 
disease affecting chiefly the skin and subcutane- 
ous tissues, due to the sporotricha, which can be 
identified in culture made from the pus. Nodules 
or abscesses or ulcers appear which may be mis- 
taken for furunculosis, blastomycosis, tubercu- 
losis, syphilis, etc. Lesions may be found in the 
bones or joints or the muscles. At times the eyes, 
nose, throat, or epididymis may be invaded; or 
the infection may become general, accompanied by 
pains, fever, and malaise. The affection is cur- 
able under iodid treatment in moderate dosage. 
SPOTTED FEVER.-See Cerebrospinal Fever ; 
Tick Fever. 
SPRAINS.-A sprain is always the result of 
indirect violence, and is produced when the move- 
ments of a joint are carried beyond their physio- 
logic limits, but stop short of a permanent dis- 
placement of the articular ends-that is, dislo- 
cation. A sprain may be said, therefore, to be 
the aborted stage of a dislocation. Extensive 
muscular action may likewise produce a sprain. 
In many individuals the first injury predisposes 
to the recurrence of the condition from apparently 
trivial causes. In the majority of sprains there 
is a stretching of the capsule of the joint and of 
one or more ligaments. In severe cases there is a 
rupture of one or both of these, with consequent 
laceration of blood-vessels, and often of nerves. 
Hemorrhage into the joint and the periarticular 
structure is always present. The ligaments, as a 
rule, if torn, give way at the point of insertion 
rather than in their continuity. This is made 
manifest in milder cases by tenderness at some 
point above or below the articular line, and corre- 
sponding to the point from which the ligament 
was torn. In the tearing of a ligament from its 
osseous attachment particles of bone are not 
infrequently brought away with the detached 
fibrous structure. In severe cases the bone may 
be denuded of its periosteum for a considerable 
distance. In the sprains of childhood and ado- 
lescence this condition is not uncommon, owing 
to the great flexibility of the bone. In adults, 
on the other hand, the extreme limit of the sprain 
is the tearing away of a greater or less fragment 
of bone to which the ligament placed upon the 
stretch by the trauma has been attached. It is in 
this way that fractures of the lower end of the 
radius and of the lower end of the fibula may be 
considered as severe forms of joint distortion. 
They are sometimes known as sprain-fractures. 
In severe sprains the segment of the capsule oppo- 
site that which is put upon the stretch may be 
pinched between the articular surfaces. Thus, 
in severe sprains of the ankle pain is often felt on 
both sides of the foot. In very severe cases a 
rupture of the muscles of the accompanying joints 
may ensue. This is quite uncommon. When 
it results, the muscles give way along the line of 
attachment to the tendon. 
The symptoms of a sprain are pain, swelling, 
ecchymosis, and limitation of joint function. 
The pain at the moment of accident it often very 
severe, leading at times to syncope. When an 
examination of the joint is made, the tenderness 
will be found most marked over the articular line 
and over the insertion of the ruptured ligament. 
The swelling varies greatly in different cases, since 
it depends upon the hemorrhage within and about 
the joint. In mild cases it is limited to the peri- 
articular structures, appearing in the form of 
ecchymoses within the course of two or three 
days. The ecchymoses, owing to ruptures of 
muscles, are often found at points considerably 
removed from the affected joint. The ecchy- 
mosis following a sprain is often found at a dis- 
tance far removed from the joint without rupture 
of muscle. Often the only ecchymoses seen in 
sprains of the shoulder appear after the lapse, 
sometimes, of many days at the point of insertion 
of the deltoid. As a rule, the swelling attains its 
maximum within the course of 24 hours. In 
many cases, however, the hemorrhage into the 
joint produces a reactional hydrarthrosis, which 
reaches its maximum in from a week to 10 days. 
The degree of periarticular or intraarticular 
swelling depends entirely upon the extent of 
damage done to the ligaments and the joint 
capsule. 
The frequency with which joints are subject 
to sprain varies with their nature. The enarthro- 
dial joints, in which the range of movement is 
widest, are least subject to sprains. On the 
other hand, joints of the hinge variety are more 
frequently the seat of' such lesions. Sprains 
occur, therefore, most often in the ankle, the 
knee, the wrist, and the small joints of the hand. 
The clinical history of a sprain varies with the SPRAINS 
SPRUE 
conditions produced by it. In some cases char- 
acterized by the stretching of the ligaments 
without laceration, the pain and swelling speedily 
subside, and after a few days or a week the joint 
functions are restored. In severer cases when 
hemorrhage into the joint and periarticular 
swelling indicate extensive laceration, the prog- 
ress toward recovery is often very tedious, and 
months may pass before a final restitution to the 
normal condition takes place. In the severest 
cases circumscribed tender areas, thickening 
of the joint capsules, or chronic hydrarthrosis 
may leave the joint permanently impaired. 
Atrophy of the muscles is often found to follow 
upon severe sprain during the first 2 weeks, and 
is the result of the injury to the articular nerve 
filaments. This condition is often irreparable. 
Extensive hemorrhage into a joint is always 
significant of a tedious recovery, and frequently 
renders unfavorable the prognosis, so far as com- 
plete restoration of joint function is concerned. 
In subjects with a tendency to diathetic, and 
particularly to tubercular, disease, a sprain is 
often the exciting cause of chronic joint-disease. 
Treatment.-In the treatment of sprains abso- 
lute rest should at once be secured. Elevation 
and suspension of the affected limb at a right 
angle will often relieve the pain at once. This 
position conduces to the arrest of hemorrhage and, 
by rapidly depleting the veins, facilitates the 
absorption of the already effused blood. To 
further hasten absorption, compression by an 
elastic bandage may be considered as of prime 
importance in the treatment of sprains. Cold 
applications are often of value for the relief of 
pain. To these may be added the lead and 
opium wash, or a solution of chlorid of ammonium 
and opium, or an ichthyol ointment. Internal 
administration of opiates may become necessary 
when pain cannot be otherwise alleviated. To 
secure absolute rest, immobilization of the joint 
by means of plaster-of-Paris, starch, or silicate 
of sodium bandages is often indicated. In milder 
cases strapping the joint with strips of adhesive 
plaster is often of great value. In sprains of the 
ankle incasing the joint by well-applied adhesive 
strips permits the patient to walk within 24 hours. 
The indiscriminate use of fixed dressings must, 
however, be condemned, since their unnecessarily 
prolonged use may lead to irremediable stiffness 
of the joint. It is preferable to resort to the use 
of splints, which can be removed daily if required. 
After the subsidence of the acute symptoms of the 
sprain, the main object of treatment must be that 
of the restoration of joint function. Efforts in 
this direction should never be delayed beyond 
the second week. The chief agents in attaining 
this end are passive movements and massage 
methodically applied. In the severest forms of 
sprains, in which the intraarticular effusion is not 
absorbed by this treatment, recourse must be had 
to aspiration of the joint. 
In sprains that are not relieved by one or other 
of these methods of treatment, singly or combined, 
counterirritation by means of blisters, or, preferably 
by ignipuncture, often answers admirably. When 
there is any thickening under an especially tender 
point, recourse should be had to free incision. In 
a few cases hemorrhagic cysts have been drained 
or granulation masses removed with a curette, 
thereby permanently relieving the symptoms. 
Such a subfascial cyst as large as a hazelnut has 
been successfully drained. It was over the 
trochanter, and directly under a point that had 
been extremely tender during two years following 
a sprain of the hip. See Joints (Injuries); 
Ankle. 
SPRENGEL'S SHOULDER-Congenital Eleva- 
tion of the Scapula, Winged Scapula (scapula alata). 
This has been explained as due to an arrested de- 
velopment in the embryonic formation of the 
shoulder girdle, which prevents the normal shifting 
of the shoulder girdle from the cervical to the upper 
dorsal region, the so-called "descensus scapulae." 
In fetal life the nerves of the brachial plexus pass 
out horizontally and the angle of the scapula only 
reaches the fifth instead of the seventh rib. When 
thus arrested the muscles-trapezius, rhomboids 
and levator anguli scapulae-shorten, and fibrous 
or bony plates unite the sixth and seventh verte- 
Congenital Elevation of the Scapula, Sprengel's 
Shoulder. (Spencer and Gask.) 
bral spines and the scapula. Thus the upper angle 
of the scapula has been mistaken for an exostosis. 
Treatment.-In early life persistent exercises 
until the palms meet above the head and the flexor 
surface of the wrists can be applied to the back of 
the neck. In later cases a division of contractured 
muscle and excision of the bony plate may be 
required before exercises can be carried out 
(Spencer and Gask). 
SPRUE (Psilosis).-A tropical disease, charac- 
terized by stomatitis, chronic gastrointestinal 
catarrh, and atrophy of the liver. Emaciation, 
tympanites and diarrhea aer markedly prominent 
symptoms. The treatment is chiefly tonic and SPUTUM 
SPUTUM 
dietetic. Rest in bed and an exclusive milk diet 
should be insisted upon until there is a decided 
abeyance of the symptoms, then a very gradual 
return to normal diet. An exclusive meat and 
beef juice diet is advocated by some clinicians, 
while others recommend a diet of strawberries. 
SPUTUM.-The material discharged from the 
alveoli of the lungs, bronchi, trachea, larynx, 
pharynx, and posterior nares. 
Characteristics.-The amount of sputum varies 
both in health and in disease. In certain affec- 
tions of the lungs, as edema, gangrene, and tuber- 
culosis, the sputum is always increased in 
amount. 
Consistence.-In certain affections, as in early 
stages of croupous pneumonia, it may be so 
quantities of saline matter, and water. The saline 
matter is abundant in transparent viscid expec- 
toration, deficient in the opaque and less tena- 
cious kind, and least in the actually purulent 
sputum. 
The quantity and viscidity of ordinary mucous 
secretion is increased in simple catarrhal inflam- 
mation of the bronchial membrane. A change 
occurs when bronchitis has existed for some days, 
the secretion becoming semitransparent and 
then opaque, the color changing to a yellow or 
greenish hue. 
The sputum becomes frothy from admixture of 
air, rusty or prune-juice colored from oozing 
from the capillary vessels. Fibrinous molds of 
the bronchial tubes, chalky masses consisting of 
1. Detritus and dust-particles. 2. Pigmented alveolar epithelium. 3. Fatty degenerated and partially pig- 
mented alveolar epithelium. 4. Alveolar epithelium showing myelin degeneration 5. Free myelin forms. 6, 7. Des- 
quamated ciliated epithelium, partly changed and deprived of its cilia. 8. Squamous epithelium from the mouth. 
9. Leukocytes. 10. Elastic libers. 11. Fibrinous cast of a small bronchus. 12. Leptothrix buccalis, together 
with cocci, bacilli, and spirochetae. a. Fatty acid crystals and free fatty granules, b. Hematoidin. c. Charcot's 
crystals, d. Cholesterin. , 
Objects found in the Sputum.-(Landois.) 
thick or viscid that in inverting the receptacle 
into which it is discharged the fluid may not 
escape. 
The color varies greatly under different circum- 
stances, being at times reddish (pneumonia and 
pleurisy), greenish (edema and gangrene), blackish 
(in coal-miners), blood-tinged (phthisis). 
Normally, the odor is only faintly perceptible, 
but in putrefactive processes the odor is strong 
and frequently nauseating. 
The specific gravity ranges from 1.015 to 1.026. 
Configuration or Character.-(1) Mucoid, (2) 
purulent, (3) serous, and (4) sanguineous. There 
may be combinations of these, such as muco- 
purulent, mucoserous, serosanguineous, sanguino- 
mucopurulent, nummular, etc. 
Clinical Significance.-In health the sputum is 
a transparent, colorless, slightly glutinous liquid, 
like thin mucilage. It contains mucin, varying 
inspissated and calcified cheesy matter, are 
sometimes expectorated. 
A person having chest complaint, coughing 
frequently, and expectorating a frothy salivary 
fluid only may have pleurisy. If the expectora- 
tion is glairy, like white of egg, bronchitis may 
exist. A rusty tinge, like thick gum-water colored 
with blood, indicates pneumonia. A sudden gush 
of fetid pus points to abscess or empyema. Puru- 
lent expectoration occurs in bronchitis as well as 
in phthisis, but when long-continued and accom- 
panied by a distinct rhonchus, it invariably comes 
from a vomica. 
In phthisis the expectoration is usually salivary 
or frothy at first, the result of irritation. Later 
it becomes viscous, and subsequently dotted and 
streaked with blood. A pearly aspect next 
ensues, with whitish opaque spots. These become 
large, flocculent, and ultimately nummular. SPUTUM 
SQUILL 
Later the expectoration becomes purulent, and 
just before death is surrounded with a pinkish 
halo. By the addition of acetic acid, the sputum 
may be made transparent, and elastic tissue more 
clearly seen. The experienced eye is the best 
guide in the selection of those small pinhead-sized 
flocculi of expectoration in which microscopic 
particles of lung tissue may be detected. 
The existence of carcinoma of the lung may 
sometimes be detected by the microscope, and 
from the character of cells found, the same appa- 
ratus may indicate the part of the respiratory 
tract affected and the degree of disease existing. 
Treatment may be much guided by a study of 
the expectoration. An alteration in the nature 
of the secretion may affect the symptoms, and 
relieve the cough and dyspnea. If frothy from 
congestive disorder, warm poultices, turpentine 
stupes, or hot flannels externally may benefit, 
while fever may be reduced and irritability less- 
ened by giving salines with antimony or aconite. 
Lemon-juice, liquor potassse, and various inhala- 
tions give relief if there is a viscid or glutinous 
expectoration. lodid of potassium, given with a 
few drops of ■wane of antimony, will promote cell 
and tissue change, and make the secretion less 
adhesive. 
Senega and the gum-resins are indicated when 
mucopurulent secretion is established. In the 
form of a lozenge they may be continually used. 
Benzoin, tolu, and copaiba are of use. Acetic 
or tannic acid, given in small or frequently re- 
peated doses, reduces the quantity of secretion. 
Calomel with antimony and guaiac, as in Plum- 
mer's pill, is of the greatest service, and calls for 
much discrimination and care. Inhalation of 
tar, creosote, or oil of juniper are of benefit to the 
affected surface of the mucous membranes, while 
cod-liver oil, iron, and tonics improve the general 
health. 
Macroscopic appearance may present (1) elastic 
tissue or threads; (2) fibrinous casts, as in pneu- 
monia or certain varieties of bronchitis, diph- 
theria, etc., Curschmann's spirals, and Charcot- 
Leyden crystals (see Asthma) ; (3) Dittrich's plugs 
-yellowish-white or grayish malodorous masses 
of bacteria, fatty acid crystals and pus found in 
pulmonary gangrene, follicular tonsillitis, etc.; (4) 
echinococcus membranes; (5) various concretions 
or calcareous plugs (broncholiths and lung stones); 
(6) foreign bodies. 
Microscopic Appearance.-The specimen is 
spread on a glass slide, a cover-glass superimposed, 
and immediately examined. It may show (1) 
leukocytes; (2) red blood-cells; (3) epithelial cells; 
(4) elastic tissue; (5) animal parasites, as echino- 
coccus booklets; (6) various bacteria. 
The chief bacteria are tubercle bacillus, pneu- 
mococcus, influenza bacillus, actinomycosis, oid- 
ium albicans, and aspergillus mycelium. See 
Tuberculosis. 
Crystals in Sputum.-(1) Charcot-Leyden; (2) 
hematoidin; (3) cholesterin, as in phthisis; (4) 
fatty acid crystals; (5) tyrosin crystals; (6) 
crystals of oxalate of calcium and triple phos- 
phate. 
Chemically the sputum contains (1) albumins, 
(2) volatile fatty acids, (3) glycogen, (4) ferments, 
and (5) inorganic salts. 
After examination of the unstained specimen 
a smear should be made; the preparation should 
next be dried in the air and stained with Wright's 
stain for 3 minutes, washed and mounted. 
Pathologic Technic.-The following are the 
principal methods of procuring a concentrated 
sediment for microscopic examination: 
Biedert's Method.-Used in examining sputum 
that contains few tubercle bacilli. Mix 15 c.c. of 
the sputum with from 75 to 100 c.c. of water and a 
few drops of potassium or sodium hydroxid solu- 
tion. Boil until the sputum is thin. Place in a 
conic glass vessel, and after two days pour off the 
supernatant liquid. Stain the precipitated sedi- 
ment. 
Kaatzer's Method.-Mix the sputum with from 
a 1 to a 3 percent solution of caustic soda or potash. 
This dissolves the cells and mucus, but preserves 
the elastic fibers and bacteria. Stain the sediment. 
Clear the preparation with a dilute solution of 
acetic acid. 
Kiihne's Method.-This method is used to over- 
come the viscidity of sputum and to facilitate the 
spreading of a thin and even film on the cover- 
glass. It consists of adding to the sputum an 
equal volume of a saturated solution of borax. A 
concentrated aqueous solution of ammonium 
carbonate will reduce the consistency of less 
viscid sputum. 
Muhlhausen's Method.-This method is used to 
render the sputum less viscid. It consists in 
adding to the sputum fiom 6 to 8 times its volume 
of a 2 percent solution of caustic potash. 
The resulting mixture may then be centrifuged 
and examined. 
Preserving Sputum. Savelieff's Method.-This is 
a process of preserving sputum for purposes of sub- 
sequent examination. Let the patient expectorate 
in a receptacle containing 95 percent alcohol, in 
which the sputum may remain for several months, 
and in which it is hardened by dehydration and 
coagulation. A few drops of caustic potash solu- 
tion added to a small lump of the hardened 
sputum on a slide will liquefy it in a few minutes, 
and from this the cover-glass preparations are 
made. When dry, fix the film by passing the 
cover-glass twice through the flame of a spirit- 
lamp, wash in water to remove the potash, and 
then stain according to any of the given methods. 
Sectioning Sputum. Gabritschewsky's Method.- 
Place the denser portions of freshly expectorated 
sputum in Muller's fluid, or some other hardening 
reagent, and then embed in celloidin. Stain the 
sections in safranin, alum carmin or hematoxylin 
eosin. Aronson and Philip treat the sputum first 
with corrosive sublimate, and, according to 
Schmidt, it may be embedded in paraffin as 
well as celloidin. 
SQUILL (Scilla).-The sliced dried bulb of 
Urginea maritime,. It contains the glucosids- 
scillitoxin, acrid and bitter, the most active 
principle; scillipicrin, acting on the heart; and 
scillin, causing numbness and vomiting; also SQUINT 
STERILITY 
sinistrin, a mucilaginous principle. The scillitin 
of the older writers is a complex substance. 
Dose of the powdered drug, 1 to 5 grains. 
In small doses squill is expectorant, in larger 
doses emetic and diuretic, and in overdoses it is 
a violent irritant poison, producing nausea, vomit- 
ing, purging, gastroenteritis, strangury, bloody 
urine, perhaps suppression of urine, paralysis and 
convulsions, with death by paralysis of the heart 
in systole. Medicinal doses slow the heart, mak- 
ing the pulse stronger and slower, raising the 
arterial tension, and increasing the flow of urine 
(like digitalis). Its active constituents diffuse 
into the blood, and its systemic effects follow on 
its application to the skin and seem to be exerted 
upon the lining of the secretory organs, especially 
affecting the bronchial, gastrointestinal and 
genitourinary mucous membranes. 
Squill is employed in medicine for its expector- 
ant and diuretic effects. It is especially applica- 
ble in cardiac dropsy, combined with digitalis or 
the saline diuretics, and in chronic bronchitis, in 
which it may be associated with ipecac, ammonia, 
asafetida, or benzoin. It is used in croup, but is 
usually combined in this affection with some other 
emetic, as tartar emetic in the compound syrup, a 
mixture which may produce very depressing effects 
and should be used with caution. In whooping- 
cough and other irritant coughs with tickling 
sensations in the throat the syrup or vinegar is 
often of great service. 
In dropsy: 
1$. Powdered squill, gr. x 
Powdered digitalis leaves, gr. xx. 
Make into 10 pills. Give 1 pill after meals. 
In subacute bronchitis: 
1$. Wine of ipecacuanha, 3 j 
Tincture of squill, 5 ij 
Syrup of tolu, 5 v 
Water, o j. 
Give a teaspoonful every 3 or 4 hours. 
Preparations.-S., Acetum, "vinegar of squill," 
10 percent in strength. Dose, 5 to 30 minims. 
S. Flext. Dose, 1 to 5 minims. S., Syr., has of 
vinegar of squill 45, sugar 80, water sufficient 
quantity. Dose, 10 to 60 minims. S., Syr., 
Comp., fluidextract of squill and fluidextract of 
senega, each 80, tartar emetic 2, sugar 750, water 
to 1000. Dose, 10 minims to 1 dram, for children 
as an emetic; 20 to 45 minims, for adults as an 
expectorant. Commonly known as Coxe's Hive 
Mixture. S., Tinct., 10 percent. Dose, 5 to 30 
minims. 
SQUINT.-See Eye-muscles (Strabismus). 
STAINING.-See Pathologic Technic. 
STAMMERING.-See Speech Defects. 
STAPHISAGRIA (Stavesacre).-The ripe seed of 
Delphinium staphisagria. Its properties are due 
to an alkaloid, delphinin, and other extractives. 
Dose, 1/2 to 2 grains. It is a violent emetic, 
cathartic, and parasiticide. It lowers the activity 
of the heart, producing adynamia. It is used 
internally in asthma and rheumatism, and 
externally for itch and lice. S- Fluidextract, 
Dose, 1/2 to 2 minims. S. Ung., unof., 1 part of 
powdered seeds with 2 each of olive oil and lard. 
Delphinin, unof. Dose 1/12 to 1/4 grain. 
STAPHYLOCOCCUS.-See Suppuration; Vac- 
cine Therapy. 
STAPHYLOMA OF THE CORNEA.-A bulging 
forward of a corneal scar with an adherent iris. 
It is caused by the weakening of the corneal 
tissue, which gives way to the intraocular pressure, 
pushing the iris and 
e venthelens forward. 
Secondary glaucoma 
is not an uncommon 
complication. The 
staphyloma may be 
partial or to tai. The 
pain, loss of vision, 
and repulsive dis- 
figurement associated 
with this affection 
render the patient a 
great sufferer. 
Treatment.-Unless the condition is only that 
of a simple prolapse of the iris, the treatment is 
of no avail. When possible, abscission of the 
staphylomatous projection, forming a suitable 
stump for a glass eye, is to be preferred to enuclea- 
tion, particularly in young children, in whom the 
presence of orbital contents is necessary for the 
symmetric growth of the face. If there are signs 
of infection or internal disease, enucleation is 
peremptorily demanded. 
STAPHYLORRHAPHY.-See Cleft Palate. 
STARVATION.-See Fasting. 
STATUS EPILEPTICUS - See Epilepsy. 
STATUS LYMPHATICUS (Lymphatism).-A 
hyperplasia of the thymus, spleen, lymphatic 
glands and lymph tissues, including bone marrow, 
occurring usually in children. It is associated 
with a marked tendency to sudden death, 
either without tangible cause or subsequent to 
operation, anesthesia or antitoxin administration. 
The patient is anemic and the tonsils and thyroid 
are usually enlarged. In several cases a section 
of the enlarged thymus has been excised. There 
may be hyperplasia of the heart and aorta, and 
rickets. 
STENOCARDIA.-See Angina Pectoris. 
STERILITY.-In considering the causes of 
sterility it should be remembered that the husband 
is at fault in about 30 percent of all sterile mar- 
riages. Bilateral epididymitis is a potent factor in 
male sterility. Imperfect development of the 
sexual organs is an important cause of sterility 
in women. The ovaries may be undeveloped, in 
which case ovulation is imperfect or absent; the 
uterus may be very small, or the vagina may be 
so narrow that complete sexual intercourse is 
impossible. Obstruction in some part of the 
genital tract may cause sterility. All cases of 
atresia of the vagina, cervix, or fallopian tubes 
would come under this class. The two former 
conditions are usually congenital, the latter is 
usually the result of inflammation. Tumors and 
polypi may act as sources of obstruction, as may 
also displacements of the uterus. Chronic infiam- 
Complete Staphyloma. STERILIZATION 
STIMULANTS 
matory conditions of the tubes and ovaries, uterus, 
and vagina are frequent causes of sterility. 
Inflammation of the ovary may prevent ovulation 
by destroying the glandular substance, or by caus- 
ing thickening of the capsule, which prevents 
rupture of the follicle and escape of the ovum. 
Inflammation of the uterine and vaginal mucous 
membrane causes sterility mainly on account of 
the leukorrheal discharge that accompanies it. 
This is particularly true of inflammation due to 
gonorrhea. Cancer of the cervix obstructs the 
cervical canal, and at the same time produces a 
profuse leukorrhea. 
The treatment will, of course, consist in eliminat- 
ing the cause whenever this is possible. If the 
condition is due to errors in development, little 
or no hope of cure can be entertained. Atresia 
or congenital narrowness of the cervix or vagina 
may be treated by incisions or dilatation. If dis- 
placed, the uterus must be replaced. Tumors and 
polypi require removal. 
Inflammatory conditions require appropriate 
treatment. If the tubes and ovaries are affected, 
little good can be accomplished; if the inflamma- 
tion is confined to the uterus and vagina, treat- 
ment is very effective. In a certain small per- 
centage of sterile marriages the sterility is un- 
doubtedly the result of incompatibility. These 
cases are usually not benefited by treatment. 
STERILIZATION.-The condition of rendering 
sterile, infertile, or incapable of reproducing. In 
bacteriology the destruction by heat of the 
spores or mature forms of bacilli, micrococci, or 
other forms of microscopic life. In most instances 
a temperature of 100° C. (212° F.) devitalizes not 
only the mature forms, but the spores as well. 
The methods of sterilization of instruments, 
dressings, ligatures, etc., are fully discussed under 
Abdominal Section (g. v.). See also Disinfec- 
tion, Milk (Sterilized). 
STERNUM, INJURIES.-Fracture of the sternum 
is exceedingly rare, except when there exists 
injury to other bones connected with it. The 
fracture may be transverse, oblique, or longitu- 
dinal. Such injury with dislocation (most usual 
at the junction of the manubrium with the glad- 
iolus), is often complicated by laceration of the 
pleura, pericardium, or other injury to the lung. 
Attempts at reduction are most difficult, although 
it has been accomplished by manipulation in a 
few cases. The prognosis in uncomplicated 
fracture or dislocation of the sternum is favorable. 
In complicated cases the mortality is high. 
Treatment.-When overriding exists, reduction 
may be obtained by bending back the body over 
a firm pillow, and then ordering deep respiration; 
or reduction may be affected under ether. When 
corrected, the deformity tends to recur, and the 
bones often unite in faulty position, with no dis- 
astrous sequels. Fragments should not be cut 
down upon or hooked up unless complications are 
present. After reduction, adhesive strips may 
be placed laterally, extending down from the axil- 
lary line and running vertically from well above 
the seat of fracture to the ensiform cartilage. An 
anterior figure-of-eight bandage may envelop the 
breast. A circular bandage of the chest, a 
posterior figure-of-eight, holding back the shoul- 
ders, may suffice. A large compress held by ad- 
hesive plaster and a broad tight roller may be 
employed. The erect or semierect position in bed 
favors easy respiration, and antagonizes the 
tendency to displacement. When the ensiform 
cartilage is bent in so as to cause great pain or to 
injure the stomach, it should be excised. 
STERNUTATORIES.-See Errhines. 
STERTOR.-The noisy breathing of a person 
in a state of coma. There exists a paralytic con- 
dition of the muscles of the lips, cheeks, tongue, 
fauces, and soft palate. The latter becomes a 
flaccid curtain moving to-and-fro with respiration 
-a similar movement occurring in the cheeks and 
lips. The tongue falls toward the pharynx, 
mucus collects in the mouth, and, becoming 
mixed with air, appears frothy at the mouth. As 
a result of these conditions, there is a snorting 
noise. 
STETHOSCOPE.-An instrument for ascertain- 
ing the condition of the organs of circulation and 
respiration by their sounds. It consists of a 
hollow tube, one end being placed over the 
locality to be examined, the other at the ear of 
the examiner. A binaural form of the instrument 
consists of a Y-shaped tube-the flexible branches 
being applied each to an ear of the listener. By 
this.means not only are all extraneous sounds shut 
out, but an intensified sound is conveyed to the 
ear. The Phonendoscope (g. v.) is a recent 
modification. See also Chest (Examination). 
STILLINGIA (Queen's-root).-The root of S. 
sylvatica, or " queen's-delight." Its active prin- 
ciple is not known. It is expectorant, diuretic, 
and sialagog, with reputed alterative properties; in 
larger doses, emetic and cathartic. It is used with 
sarsaparilla as an antisyphilitic in the tertiary 
stage. It is valuable with quinin in intermittent 
fever. Dose of the powdered root, 10 grains to 1 
dram; of the fluidextract, 10 minims to 1 
dram. 
STIMULANTS.-A term which is used in 
various senses when applied to medicinal agents. 
Alcoholic preparations, which are true narcotics, 
are commonly termed "stimulants," and the same 
expression is employed to designate any agent 
which excites even briefly the organic action of 
any part of the system. All excessive stimulation 
reacts into depression, and most of the agents 
which stimulate the nerve centers at first will soon 
depress and finally paralyze them. In many cases 
the action is one of progressive stimulation 
primarily and progressive paralysis afterward, 
affecting the centers in the inverse order of their 
development, the highest or latest developed 
centers being affected first, the lowest or oldest 
ones last. These laws are well exemplified in the 
action of Alcohol (g. v.) upon the nervous system. 
Diffusible Stimulants are those which have a 
prompt but transient effect on the general system, 
such as alcohol, ammonia, camphor. Spinal 
Stimulants exalt the functions of the cord, as 
strychnin, picrotoxin, ergot, atropin, phosphorus. 
Cardiac Stimulants increase the action of the heart, STINGS 
STOMACH, CATARRH 
as alcohol, adrenalin, strychnin, atropin, and mor- 
phin in small doses; also squill, convallaria, cimi- 
cifuga and digitalis, which slow but strengthen the 
cardiac action. Respiratory Stimulants directly 
stimulate the respiratory center, as ammonia, 
strychnin, apomorphin, belladonna. Vascular 
Stimulants, as alcohol, chloroform, ether (all three 
in very small quantities), adrenalin, ammonia, 
strychnin, digitalis, and squill, acting on the vaso- 
motor center; and the nitrites, belladonna, 
electricity, volatile oils, acting as local dilators of 
the vascular system. Cerebral Stimulants, as 
alcohol, opium, belladonna, caffein, cocain, canna- 
bis, chloroform, ether, tobacco. Renal Stimulants, 
as the diuretic group. Stomachic Stimulants, as 
the aromatics, volatile oils, vegetable bitters, 
mineral acids, nux vomica, mustard, capsicum. 
Hepatic Stimulants, as nitro muriatic and nitric 
acids, and the cholagog purgatives podophyllum, 
jalap, leptandra, euonymin, iridin. Intestinal 
Stimulants, as mercurials, elaterium, colocynth, 
jalap, scammony, podophyllum, which affect the 
glandular apparatus-and belladonna, physo- 
stigma, nux vomica, rhubarb, senna, aloes, 
frangula, cascara, which chiefly affect the muscular 
fibers and the intestinal nerves. Cutaneous 
Stimulants, as the diaphoretic group, and the 
rubefacients, mustard, capsicum, turpentine, am- 
monia. Local Stimulants increase common sensi- 
bility to the extent of producing pain, chiefly by 
direct action upon the end-organs of the sensory 
nerves in the skin, though some act probably by 
stimulating the local circulation, as in inflammation. 
The principal members of this sub-division are: 
heat, cold, faradism, alcohol, ether, chloroform, 
phenol, creosote, ammonia, mineral acids, volatile 
oils, acrid essential oils, metallic salts, veratrin 
(at first), cantharis (at first). 
STINGS.-See Bites and Stings. 
STOKES-ADAMS SYNDROME.-See Heart 
Block. 
STOMACH, CANCER. Varieties.-(1) Hard 
cancer (scirrhus); (2) colloid cancer; (3) soft 
cancer (medullary); (4) epithelioma. 
Etiology.-(1) Heredity, (2) adult life, (3) male 
sex, and (4) ulcer of the stomach are the most 
common etiologic factors. 
Pathology.-Cancer of the stomach is generally 
a primary affection, and next to cancer of the 
uterus is the most frequent seat of this disease. 
It is generally situated at the lesser curvature and 
pyloric end of the stomach. The medullary 
variety is very prone to undergo ulceration. In 
many cases cancer of this organ may be secondary 
to the disease elsewhere. 
Symptoms and Clinical Course.-There are no 
characteristic symptoms in the early stages. 
Later it presents the following: Constant and 
localized pain; dyspeptic manifestations; con- 
stipation; rapid emaciation; cachexia; moderate 
anemia and leukocytosis; hematemesis, causing 
vomiting of a "coffee-ground" material long after 
eating; absence of free hydrochloric acid in the 
gastric contents one hour after a test-breakfast; 
and the presence of a tumor in the epigastrium. 
Diagnosis.-(See also Gastritis (Chronic)). 
Prognosis.-The disease is inevitably fatal. The 
duration is from 1 to 3 years. 
Prophylaxis.-Since chronic ulceration has been 
found to be one of the most frequent causes of 
cancer of the stomach, early excision of gastric 
ulcers is advisable. 
Treatment is merely palliative. If the stomach 
is intolerant of food, resort must be had to rectal 
alimentation, and the best that can be hoped for is 
to prolong life, which can only be one of suffering. 
Any formula for rectal alimentation may be used. 
See Stomach (Ulcer). 
Peptonized milk may also be given. It may be 
made as follows: Extract of pancreas (5 grains), 
sodium bicarbonate (15 grains), and a cupful of 
water; to this add a pint of milk. Heat for 10 
minutes at a temperature of 100° F. 
1^. Pepsin, 5 j 
Dilute hydrochloric acid, 3 jss 
Syrup, 3 iij 
Water, add enough to make, 3 ij. 
Teaspoonful after meals. 
1$. Strychnin sulphate, gr. ss 
Solution of iron and ammon- 
ium acetate, 3 vj. 
Two teaspoonfuls after meals. 
For the pain, morphin (1/4 grain) may be given 
hypodermically. For the indigestion and similar 
symptoms, see Gastritis (Chronic). 
The operative treatment is discussed under 
Stomach (Surgery). 
STOMACH, CATARRH.-See Gastritis. 
Cancer of the 
Stomach. 
Tumor of the 
Liver. 
Tumor of the 
Spleen. 
Cancer of the 
Pancreas. 
Tumor of the 
Colon. 
1. Tumor nearly always 
1. Tumor usually in 
1. Gastric cancers sei- 
1. Tumor in region of 
1. Tumor in umbilical 
present in region of 
pylorus (epigastric re- 
gion). 
right hypochondriac 
region. 
dom present in area 
of spleen. History of 
malaria or symptoms 
of leukemia. 
epigastrium. 
region. 
2. Tumor hard, uneven, 
2. Tumor hard, uneven, 
or nodular and tender. 
2. Tumor hard, usually 
2. Tumor hard, nodu- 
2. Tumor may be hard 
and tender. 
smooth. 
lar, and tender. 
or soft. 
3. Tumor slightly mov- 
able. 
3. Usually movable. If 
carcinoma, immov- 
able. । 
3. Tumor immovable... 
3. Tumor immovable... 
3. Tumor movable. 
4. Dulness on percus- 
4. Increased area of 
4. Increased area of 
4. Increased area of 
4. Increased area of dul- 
sion. 
dulness in right hypo- 
chondriac region. 
dulness in left hypo- 
chondriac region. 
dulness when stomach 
is collapsed. 
ness, and separable 
from the stomach. STOMACH, DILATATION 
STOMACH, EXAMINATION 
STOMACH, DILATATION.-A permanent in- 
crease in the capacity of the stomach, due to 
atony or pyloric obstruction. 
Synonyms.-Gastrectasia; gastric atony; myas- 
thenia. 
Etiology.-(1) Overeating; (2) beer drinking; (3) 
rapid fermentation of gastric contents; (4) certain 
diseases-heart-disease, tumors (cancer) of pylorus, 
typhoid fever, tuberculosis, tabes dorsalis; (5) it 
may be secondary to chronic gastritis. 
Pathology.-The muscular coats of the stomach 
are much thinner than normal, and the mucous 
membrane is in a state of atrophy. There are 
evidences of hyperplasia of connective tissue of 
the muscular coat in certain areas. The capacity 
of the stomach may be equal to 6 pints of fluid. 
Symptoms and Clinical Course.-There is a 
sense of fulness in the epigastrium, which may be 
visibly distended; eructation of gas, copious 
vomiting of liquid material, containing small 
particles of food and having a very sour odor, 
are also prominent signs. The appetite is lost, 
the tongue is coated, the bowels are constipated, 
and the urine is high colored and scanty. Emacia- 
tion and anemia may be quite marked. 
Physical Signs.-Inspection may detect the out- 
line of the organ, which distends the abdominal 
walls. In cases of complete obstruction of the 
pylorus the peristaltic wave can be traced. 
Palpation confirms inspection. 
Percussion.-The patient is placed in a standing 
position; percussion should be made from the lower 
border of the ribs in the midsternal line downward. 
A tympanitic note will be detected over the upper 
area of the stomach, and dulness over the base of 
the organ on account of the fluid contents gravi- 
tating to this position as the patient stands erect. 
Immediately below this dulness tympany again 
begins, due. to the position of the bowel. If the 
patient assumes a horizontal position, the con- 
tents of the stomach gravitate posteriorly, and 
tympany will exist where dulness was previously 
found. 
Should the area of the stomach be shown to be 
below the navel, the organ is considered to be in 
a state of dilatation. It it is desired to confirm 
the diagnosis, the organ may be dilated artifically: 
give tartaric acid (1 dram) dissolved in water 
(2 ounces), and subsequently sodium bicarbonate 
(1 1/2 drams) in the same quantity of water. 
Malignant disease must first be excluded. 
Diagnosis depends upon the symptoms and 
physical signs. 
Prognosis.-If due to malignant growth, the 
prognosis is unfavorable. If due to simple atony, 
relief may be obtained. 
Treatment.-The first indication is removal of 
the cause if possible. The patient must accustom 
himself to smaller quantities of food at each meal. 
A quart of liquid may be allowed in the 24 hours. 
Constipation must be treated on general princi- 
ples: first by correcting the diet, then by giving 
salines-Epsom salt (2 drams) or Rochelle salt 
(2 drams)-before breakfast. Fluidextract of 
cascara (1/2 dram) with an equal quantity of 
glycerin may be given at bedtime. Lavage of the 
stomach may be practised every 2 days. See 
Lavage. 
I|. Strychnin sulphate, gr. 1 /4 
Dilute hydrochloric 
acid, 
Pepsin, 
each, 5 j 
Syrup, 5 iij 
Water, add enough to make, o iij. 
Two teaspoonfuls after meals. 
T|. Creosote, 5 j 
Compound tincture of carda- 
mom, add enough to make § iij. 
Teaspoonful half-hour after meals. 
STOMACH, EXAMINATION.-The patient 
should be in the recumbent posture in a strong 
light. 
Inspection detects the outline in very thin 
persons, and sometimes the peristaltic wave and 
the presence of tumors. 
Palpation.-The hand should be placed flat upon 
the abdomen, the fingers making gradual pressure, 
at the same time having a rotatory movement. 
By this method are detected epigastric pulsation, 
as in cardiac disease, anemia, aneurysm of aorta, 
the shape and position of epigastric tumorS, and 
localized pain. 
Percussion yields a tympanitic note by which 
may be detected the correct outline. The upper 
and right lateral boundary extends along the 
lower border of the right lobe of the liver; the left 
lateral boundary to the inner border of the spleen. 
The stomach has no fixed position, as it is very 
movable. To determine the lower boundary, 
percussion should begin in the region of the umbili- 
cus, gradually going upward until an impaired 
resonance is elicited. 
The stomach may be increased in size by (1) 
gaseous distention, (2) large quantity of liquid or 
food, or (3) tumors. 
The stomach is displaced downward in (1) 
emphysema, (2) left pleural adhesion, (3) enlarge- 
ment of the liver or spleen, (4) tight lacing, or 
(5) deep inspiration. 
The stomach is displaced upward in (1) tym- 
panites, (2) ascites, (3) tumors, or (4) during the 
latter months of pregnancy. 
The correct outline of the stomach may be 
obtained by making separate solutions of sodium 
bicarbonate (1 1/2 drams) and tartaric acid (1 
dram), each in half a glass of water. The tartaric 
acid solution should be given first, followed imme- 
diately by the sodium bicarbonate. Malignant 
disease should always be excluded before causing 
rapid dilatation of the stomach. 
Auscultation detects (1) the normal deglutition 
murmur, and (2) obstruction at the cardiac 
orifice of the stomach. 
1. To obtain the normal deglutition murmur, 
place the stethoscope over the esophagus and just 
below the xiphoid cartilage, and allow the patient 
to drink a small quantity of water. The first 
murmur in health occurs immediately, and is 
hissing or spurting in character. Within from 
5 to 7 seconds the second sound is heard; it is due STOMACH, INJURIES 
STOMACH,SURGERY 
to the escape of the water from the esophagus into 
the cardiac end of the stomach, and has a gurgling, 
sprinkling, or splashing sound. 
2. When there is obstruction at the cardiac 
orifice of the stomach, the second is delayed in 
some instances for over a minute. See Stomach- 
contents. 
STOMACH, INJURIES. Rupture.-Traumatism 
seldom causes a laceration except when the 
stomach is overdistended with liquid or semi- 
liquid material. It may be severely injured 
through contusion of the abdominal wall, in which 
case the rent is found near the pyloric orifice. 
Laceration of the mucous membrane has been 
found resulting from lavage of the stomach. In 
the case of incomplete tears there are hemat- 
emesis and severe localized pain, resembling 
gastric ulcer in its gnawing character, together 
with symptoms of shock. If the wound of the 
organ is large, and there is a great extravasation 
of the stomach-contents, a general peritonitis 
is produced. If, on the contrary, the wound is 
small, there is a tendency to form adhesions 
whereby the inflammatory area will be isolated 
from the general peritoneal cavity. 
'^Treatment.-Whenever the stomach is per- 
forated, the indication is to explore the parts after 
abdominal section, and remove all infection that 
may have taken place in the peritoneal cavity 
by the extravasation of the intestinal contents. 
The wound in the stomach is then sewed by means 
of Lembert sutures, and is closed according to the 
general rules of antiseptic surgery. 
Foreign Bodies.-These generally consist of 
such substances as have been swallowed accident- 
ally, or of concretion from the constant ingestion 
of such substances as hair and wool, which finally 
agglutinate into a mass. The only treatment for 
such a condition is to open the organ (gastrotomy) 
and remove the mass; if, however, the foreign 
body is of small dimensions, such as a coin, it 
may safely be allowed to pass onward. See 
Stomach (Surgery). 
Hernia of the Stomach.-The stomach has 
been rarely found in inguinal hernias and still less 
frequently in femoral hernias. The diagnosis is 
not usually made until operation, and fatal 
results are common. Herniotomy is indicated 
in such cases, and the stomach should be dealt 
with by simple reposition or resection of a portion 
of its wall if damaged beyond the possibility of 
repair. The stomach may also prolapse in a 
diaphragmatic hernia. 
STOMACH, NEUROSES.-See Gastric Neu- 
roses. 
STOMACH, SURGERY.-Gastrolysis, or loosen- 
ing the stomach from adhesions, has been found 
necessary in a number of cases in which extensive 
adhesions have given rise to severe pain and 
decided disturbance of digestion. 
Such adhesions arise most frequently as a result 
of gastric ulcer, but they may be caused by 
general peritonitis or inflammatory conditions 
in neighboring organs, such as the liver, gall- 
bladder, colon, pancreas, spleen, or abdominal 
wall. The condition is difficult of diagnosis, 
as there are no distinctive symptoms, and it is 
seldom that the cause of the disorder has been 
determined before operation. The adhesions 
may be very broad or they may be band-like, in 
which case there is often danger of constriction 
of the bowel. Operation by celiotomy and exci- 
sion of the bands or loosening the adhesions is 
usually followed by perfect relief. In some cases 
of very extensive adhesions producing stenosis of 
the pylorus or partial hour-glass contraction, 
gastroplasty, resection, or partial gastrectomy 
may be necessary. 
Gastrotomy for the removal of foreign bodies is 
indicated in cases in which the nature of the foreign 
body is such that it either cannot pass or can 
only pass with great risk, or if urgent symptoms 
arise. More or less sharp or jagged bodies, such 
as pins, small knife-blades, and bits of glass, have 
often been well tolerated by the stomach; but in 
cases accompanied by serious pain and discomfort 
operation is imperative. Any body the size of 
which permits it to pass the cardia will usually 
pass the pylorus, but this is not true of long 
bodies. Aggregations of small bodies, such as 
masses of hair, fish-bones, or pebbles, sometimes 
require removal. In case severe and continued 
pain or distress is present, with or without nausea, 
vomiting, and hemorrhage, operation is demanded. 
Diagnosis.-Usually the history of the case 
leaves no doubt as to the diagnosis, and very often 
the object may be felt through the abdominal 
wall. In children, insane persons, etc., in whom 
there is doubt as to the condition, the use of the 
X-ray will often furnish valuable information. 
Gastrotomy for the relief of stricture of the 
esophagus may be necessary in cases in which it is 
impossible or undesirable to dilate by means of a 
bougie passed by the mouth. This is often the 
case if the stricture is located low down in the 
esophagus, particularly in cases in which the 
esophagus becomes dilated or pouched above the 
stricture. Immediate dilatation by bougies or 
the fingers may be practised or the stricture may 
be divided by Lange's specially constructed knife- 
blades or by Abba's bow-string method. In such 
cases the stomach is immediately closed. If, 
however, a large portion of the esophagus is 
constricted and repeated dilatation is required, a 
temporary gastric fistula may be established, 
which will either close spontaneously, or may be 
closed at a subsequent operation. 
Abbe's Bow-string Method.-A string is passed 
into the esophagus through the mouth, or, better, 
through an opening into the esophagus in the 
neck; then it is passed into the stomach and out 
through the gastric incision: the stricture is made 
tense by a bougie, and the string, sawed back and 
forth, will only divide the tense stricture and not 
the relaxed portion of the esophagus. 
Exploratory gastrotomy has been performed in a 
number of cases in which no positive diagnosis 
could be reached by any other means; discovery 
has thus far followed in every case, and in most 
cases pathologic conditions have been found and 
successfully treated. The slight danger from 
the operation and the facility which it offers for STOMACH, SURGERY 
STOMACH, SURGERY 
correct diagnosis in cases of hemorrhage arising 
from erosions or small ulcers, symptoms due to 
incipient carcinoma, polypi of the mucous mem- 
brane, and other obscure conditions, makes the 
operation thoroughly justifiable. 
Exploratory operations are strongly indicated 
"in cases of rapidly developing cachexia and 
emaciation with the symptoms of chronic gas- 
tritis and absence of HC1. Tentative treatment 
should not be prolonged over three weeks. It is 
not nearly so serious a fault to have caused the 
opening of a stomach and found nothing operable, 
as to permit a case to continue and find out at the 
autopsy only that it was a circumscribed carci- 
noma, the removal of which might have prolonged 
life for years." (Hemmeter.) 
The Operation of Gastrotomy.-Before anesthe- 
tizing the patient for operation, it is desirable 
to wash out the stomach, and 8 or 10 ounces of 
some innocuous fluid may be left to aid in finding 
the stomach. The distention of the stomach by 
large quantities of gas, as has been suggested by 
some surgeons, is not without its danger of infect- 
ing the peritoneum, particularly if the stomach- 
wall is ulcerated, nearly perforated by a foreign 
body, or rendered friable by disease. If stricture 
of the esophagus is present, this lavage is, of 
course, impossible. The incision may be made 
parallel to the left costal margin, or, if the foreign 
body is large, in the median line. Before opening 
the stomach, it should be brought out of the 
abdominal cavity, if possible, and carefully ex- 
amined to make certain that the stomach and not 
the transverse colon is being dealt with; the colon 
is recognized by its longitudinal muscular bands. 
It is then walled off with iodoform gauze to avoid 
contamination of the peritoneum. Stay loops 
may be passed through the serous and muscular 
coats to aid in holding the organ. The line of 
incision in the stomach-wall is perhaps best made 
parallel to the course of the vessels-that is, 
transversely to the curvatures-but it will 
depend much upon the object of the operation; 
after this is attained the opening is closed by 
Lembert's or Halsted's mattress sutures, and 
the abdominal wound is sutured without drainage. 
Gastrostomy is the establishment by operation 
of a fistula through the abdominal and gastric 
walls, for the purpose of introducing nourishment. 
Indications.-The reason for the operation 
exists in some insuperable obstruction in the 
digestive tract above the stomach, which prevents 
the introduction of food: to prevent death by 
starvation. Perhaps the most common source of 
obstruction is malignant disease of the esophagus 
or cardia; other causes are: Syphilitic stricture, 
diverticulum of the esophagus, congenital closure, 
cicatricial contraction, chemic or traumatic 
destruction of the walls of the esophagus, ob- 
struction by the pressure of growths outside the 
esophagus, and malignant disease of the pharynx 
and mouth. 
Epithelioma is the most common variety of 
malignant growth affecting the esophagus, and it 
occurs more frequently in males after middle life. 
Fibrous stricture is usually a sequence of ulcera- 
tion caused by swallowing very hot water or 
caustics, or, in at least two recorded cases, as a 
sequel of typhoid fever. It may be due to con- 
stant traumatic irritation or injury, as sword 
swallowing. Benign tumors outside the esoph- 
agus, taking their origin in its walls, are rarely a 
cause of obstruction; this is also true of growths in 
the neck or thorax, such as aneurysms of the aorta 
or innominate artery, tumors of the larynx, etc. 
Diagnosis of Esophageal Obstruction.-The 
most important subjective symptom is difficulty 
in swallowing, which gradually increases until 
there is absolute inability to swallow first solid 
food and later food of any sort. Pain at the 
part affected radiating to the stomach and mouth 
is frequent. There may be tenderness on pres- 
sure. Food is regurgitated, in some cases mixed 
with mucus, pus, and blood. There is digestive 
disturbance, and loss of strength and weight. 
Objective signs are obtained by passing the esoph- 
ageal bougie and by auscultation. The bougie 
should be soft and flexible and must be passed 
with great care, as deaths have been reported 
from the rupture of aneurysms, perforation of the 
pleura and of the esophagus itself, even by skilled 
surgeons. Considerable familiarity with the 
sounds of deglutition in normal and diseased con- 
ditions is necessary for satisfactory diagnosis by 
this means. 
The operation of gastrostomy has been per- 
formed by various methods, the object aimed for 
in most of them being the avoidance of leakage 
of the gastric contents and subsequent excoria- 
tion of the skin, which followed the earlier 
operations in which the stomach was fixed 
to the abdominal wall and opened directly. 
The operation which was devised independ- 
ently by Ssabanejew and Frank avoids leakage 
and the necessity for wearing a tube, and is 
generally to be preferred. According to this 
method an incision is made along the left costal 
border, and the stomach is drawn out into 
a cone about 11/2 inches (3.9 cm.) long. A 
second incision is made an inch (2.5 cm.) above 
the costal border; the skin between the two 
incisions is undermined; the apex of the cone of 
the stomach, which has already been fixed by 
suture at the first incision, is drawn out through 
the second incision, passing under the bridge of 
skin, and is fastened by sutures. The abdominal 
incision is then closed, and the apex of the stomach 
is opened immediately. The obliquity of the 
canal and the pressure of the strip of skin prevent 
leakage, and a tube is introduced only when food 
is given. 
Witzel's method may be used in case the 
stomach is so firmly contracted that it is impos- 
sible to draw out a cone sufficiently long to pass 
under the bridge of skin. According to this 
method, after opening the abdomen and walling 
off the field of operation with gauze, a small 
opening is made toward the cardiac extremity, 
into which a catheter (about No. 25 French), or 
other similar rubber tube, is introduced into the 
stomach; about 2 1/4 inches (5 or 6 cm.) of the 
protruding part of the tube are then buried in the STOMACH, SURGERY 
stomach-wall by Lembert sutures; the stomach 
is then fixed to the abdominal wall, and the 
parietal incision is closed about the tube. The 
tube is clamped, and in rare instances it is possible, 
after a time, to withdraw it. 
The Stamm-Kader Method.-The stomach is 
exposed and opened as in the Witzel operation. 
A rubber tube is introduced and, with catgut, the 
edge of the gastric wound is sutured to the tube. 
With celluloid hemp or silk the gastric serosa, 
STOMACH, SURGERY 
Gastroenterostomy is the operation of establish- 
ing a permanent fistula between the stomach and 
the upper part of the small intestine. 
Indications.-The chief object of the operation 
is to empty the stomach quickly, particularly in 
cases of obstruction at the pylorus, or of ulcer 
and obstinate disturbance of digestion. In case 
of malignant disease this operation is indicated 
if the disease has progressed so far as to make 
pylorectomy or resection impracticable. In the 
nonmalignant forms of pyloric stenosis this oper- 
ation is to be preferred only when the stenosis is 
extreme or the thickening is great, or in case 
of recurrent stenosis. The operation has also 
been performed with encouraging success, spe- 
cially by French surgeons, in the treatment of ob- 
stinate digestive disturbances, particularly if asso- 
ciated with gastric ulcer. 
For the symptoms and diagnosis of carcinoma 
and ulcer of the stomach, see Stomach (Cancer, 
Ulcer). 
The Operation.-It is essential that the stomach 
be empty at the time of operation. The practice 
of washing it out immediately before the anes- 
thetic is begun, however, has been generally aban- 
doned, as it often causes troublesome vomiting and 
distresses the patient. For three days prior to the 
operation the stomach may be washed out morning 
and evening, but for twelve hours before the opera- 
tion the viscus should be kept at rest, all food 
being interdicted. In order that digestion and 
absorption be not interfered with, it is necessary 
that the upper part of the intestine be selected for 
anastomosis. The beginning of the jejunum is 
the only fixed part of the small intestine, and it 
can usually be found without much difficulty just 
below the pancreas on the left side of the verte- 
bral column near the root of the mesentery. It is 
important that the upper end of the bowel shall 
be toward the cardiac end of the stomach, so that 
the peristaltic waves shall be in the same direction. 
Union may be effected by direct suturing or by 
some of the numerous buttons, bobbins, or plates 
that have been devised. The following points 
are essential, regardless of what method of oper- 
ating is selected. 1. The opening must be a 
large one, at least 21/2 to 3 inches long. 2. 
The orifice must be placed at the lowest part of 
the stomach as the patient stands. 3. Some of 
the mucous membrane of the stomach and intestine 
should be removed in order to prevent valve 
formation. 
Methods.-(1) Posterior gastrojejunostomy 
without a loop. 2. Posterior gastrojejunostomy 
with a loop. 3. Roux's Y method. 4. Anterior 
gastrojejunostomy. 5. Anterior or posterior 
gastrojejunostomy with enteroanastomosis. Of 
these methods it is probable that posterior gastro- 
jejunostomy without a loop is most frequently 
applicable. If the posterior wall of the stomach 
is more involved by carcinoma than the anterior 
wall, naturally the anterior operation is preferable. 
Mayo states that it is to be preferred also in cases 
in which the mesentery is very short or contains 
much fat, and in those in which the vascular loop 
coming from the superior mesenteric artery is 
about 1/4 inch distant from the wound, is joined 
to the side of the tube all around it a short distance 
from the wound. A second row of these serous 
sutures is next inserted. This causes an inversion 
or invagination of the stomach-wall, which serves 
as an efficient valve. With Lembert sutures the 
stomach is united around the tube to the parietal 
peritoneum. The outer portion of the tube is 
brought through the abdominal wound at a con- 
Parietes 
Parietes 
venient point. The excess of abdominal wound 
is closed. The Stamm-Kader operation is the 
only one applicable when the stomach is much 
diminished in size. It is an excellent, perhaps 
the best, method. 
In feeding by the fistula the food should at first 
be given in small quantities and of such a nature 
as to be readily absorbed. Peptonized milk or 
pounded beef may be administered alternately 
with starchy and fatty food. Later on, the quan- 
tity may be somewhat increased, as too frequent 
feeding irritates the stomach and the fistula. 
Half a pint given slowly every 4 hours is a fair 
average of quantity and frequency. 
The mortality from the operation is about 
25 percent in malignant cases, and no doubt will 
be much reduced as operation is resorted to earlier. STOMACH, SURGERY 
STOMACH, SURGERY 
small so that on opening the posterior layer of the 
gastrocolic omentum it would be very close to 
the artery. 
The mortality after gastroenterostomy at 
present varies from 3 percent in benign to 20 
percent in malignant cases. According to Mayo, 
the chief causes of death are exhaustion, exhaus- 
tion with vomiting, pneumonia, and detachment 
of the anastomosed intestine. 
The Operation. Posterior Gastroenterostomy. 
-Mayo's "No loop" method. The stomach is 
exposed by an incision 3/4 inch to the right of the 
median line. The whole 'stomach and duodenum 
are examined. No matter what condition is 
apparent at the first glance, there may be some- 
to tear a hole in the mesocolon and expose the 
posterior surface of the stomach. 
A hole is torn through a nonvascular area of 
mesocolon. A portion of the posterior wall of 
the stomach is pulled through this hole. By 
separating the gastrocolic omentum and with it 
the gastroepiploic artery, from the greater 
curvature of the stomach for a short distance it 
is easy to pull a portion of the anterior as well as of 
the posterior wall of the stomach through the rent 
in the mesocolon. It is important to do this in 
order to drain the very lowest point of the stomach. 
A gastroenterostomy clamp is applied to a fold 
of stomach, including about 1 inch of the anterior 
wall. The direction of the clamp and of the con- 
tained fold must be from right 
to left, and from above downward. 
A similar gastroenterostomy 
clamp is applied to the jejunum 
along its long axis. The highest 
point of the gut grasped in the 
clamp must be 1 1/2 to 3 1/2 
inches from the duodenojejunal 
junction. 
The two clamps are placed side 
by side on the abdominal wall so 
that the portions of the stomach 
and jejunum to be anastomosed 
are well outside the abdomen, 
embraced by the clamps. The 
belly is protected with pads and 
the anastomosis is made in exactly 
the same way as that described 
for enteroenterostomy. See In- 
testinal Anastomosis. 
The edges of the rent in the 
mesocolon ought to be stitched to 
the stomach. The viscera are 
returned to the abdomen and the 
wound is closed. 
Anterior Gastroenterostomy. 
Wolfler's Operation.-The abdo- 
men is opened by an incision in 
or near the middle line, between 
the umbilicus and the ensiform 
cartilage. The cut is about 4 in- 
ches long and may be enlarged by 
a transverse section of the rectus. 
The small intestine is exposed 
by pulling the omentum upward 
and to the left. The jejunum is 
then to be found; the loop of gut 
is emptied and clamps are applied. 
On the lowest possible point of 
the anterior wall of the stomach 
a spot is selected for the stomach 
opening. This portion of stomach and the loop 
of jejunum are pulled out of the belly and the 
cavity protected with gauze pads. An anasto- 
mosis is made between the stomach and the je- 
junum, using either sutures or the Murphy but- 
ton. The method of making the anastomosis is 
identical with that of enteroenterostomy (lateral 
anastomosis). 
The field of operation is cleansed, all instru- 
ments which have touched the mucosa are put 
Colon and Transverse Meso-colon Pulled Upward Exposing Jejunum.- 
{Binnie.) 
Exposure of stomach through rent in meso-colon. Limited separation of gastro- 
colic omentum and gastro-epiploic vessels from lowest point of greater curvature 
of stomach permits exposure of small portion of anterior wall of stomach. Fold 
of stomach in clamp consists of a small portion of the anterior and large portion 
of the posterior wall. 
thing else present, e. g., a trifid stomach, which it 
is necessary to recognize. 
The transverse colon is drawn out of the wound 
and by pulling upward and to the right, as much 
of the mesocolon is brought up with it that the 
jejunum becomes visible. The jejunum is picked 
up about 3 inches from the origin. The fold of 
peritoneum is noted passing from the jejunal 
origin to the transverse mesocolon; near where this 
fold joins the mesocolon is the best place in which STOMACH, SURGERY 
STOMACH, SURGERY 
aside. The line of union is inspected, and if 
necessary, reinforced with a few Lembert sutures. 
If the point of union causes the intestine to kink 
sharply, this may be remedied by a few stitches 
uniting to the stomach a little more of the afferent 
or efferent portions of gut or of both. The wound 
is closed. 
The after treatment is very important. As 
soon as the patient has recovered from the anes- 
thetic he should be placed in the semierect posi- 
tion, as this facilitates the passage of fluid through 
the anastomotic opening and also tends to pre- 
vent pulmonary congestion. In treating these 
patients Mayo begins to give them one ounce of 
hot water by mouth at the end of sixteen, eigh- 
teen or twenty hours. If it is well borne, the 
quantity is rapidly increased. At the end of 36 
hours he allows liquid food. 
Pylorectomy.-By this term is understood 
the removal not only of the pylorus, but with 
it as much of the duodenum and stomach as is 
diseased. 
Indications.-The operation is performed almost 
entirely for carcinoma of the pylorus, although 
it has been practised in a number of cases for ulcer 
and cicatricial stenosis of this region. Whether 
the operation is undertaken or not depends upon 
the extent of the growth, the amount of adhesions 
to other organs, and the extent of involvement of 
glands. In the present state of medical knowledge 
it is impossible to determine absolutely the 
existence of carcinoma in its incipiency; but if 
operation is to be more than palliative, it must be 
undertaken early. Considering the harmlessness 
and simplicity of exploratory celiotomy and the 
fatal consequences of delay, it seems justifiable 
that, in cases of obstinate gastric disturbances that 
do not yield to medical means, exploratory 
operation should be undertaken even in the 
absence of a palpable tumor. Factors that are of 
aid in the diagnosis are the existence of dilatation 
of the stomach, cachexia, an excess of lactic acid, 
hematemesis, the presence of the Oppier bacillus, 
absence of free hydrochloric acid, age past 40, and 
a diminished amount of hemoglobin and number 
of red blood-corpuscles. 
The Operation.-The preparation is the same as 
for gastroenterostomy. Various methods have 
been employed. Billroth resected the tumor, and 
as the opening in the stomach is so much greater 
than that in the duodenum, the stomach wound 
was partially closed by suture until it reached a 
size sufficient for end to end anastomosis with the 
duodenum. The anastomosis is best made lower 
than the upper end or middle of the gastric open- 
ing, to facilitate emptying the contents of the 
stomach. Kocher closes both the stomach and 
duodenum and makes a posterior end to side 
anastomosis by insertion of the duodenum in the 
posterior wall of the stomach, with or without 
Murphy's button. Czerny first performs posterior 
gastroenterostomy with Murphy's button, and 
then, after resection of the tumor, closes the stom- 
ach and duodenum. Forceps may be used to 
good advantage. 
The average mortality of the operation as' now 
done by skilful surgeons is probably from 20 to 25 
percent. Some have reported series of cases with 
a considerably lower death rate than this, Mayo 
for instance, having done 100 operations with a 
mortality of 14 percent and Kocher 58 with a 
mortality of 15 percent. 
Pyloroplasty is the term applied to operative en- 
largement of a stenosed pylorus. It has fallen 
into disfavor with the majority of surgeons, 
although a few still practise it. Mayo states that 
it failed to give relief in 30 percent of his cases and 
that another operation had to be resorted to. 
The Heineke-Mikulicz operation was devised and 
performed independently by the surgeons whose 
names it bears in 1886-87. A longitudinal 
incision is made at the seat of constriction, the 
incision is then stretched at its middle at a right 
angle to the incision, so as to dilate the strictured 
pyloric opening, and the margins of the opening 
are sutured in this new position. 
Gastroplication or Gastrorrhaphy.-The former 
is the preferable term. It is used to designate the 
operation of making a fold in the stomach-wall 
and suturing it. 
Indication.-The operation has been performed 
chiefly in the treatment of dilatation of the 
stomach, although its use has been suggested in 
threatened perforating ulcer. In case the dila- 
tation is due to malignant pyloric stenosis, 
pylorectomy or gastroenterostomy is the preferable 
operation. 
The Operation.-After opening the abdomen the 
greater curvature of the stomach is lifted up to the 
lesser curvature, thus folding the anterior wall on 
itself, and the fold is held in place by two rows of 
sutures. A similar result has been attained by 
certain operators by the use of purse-string 
sutures. 
The permanent results of the operation are not 
yet definitely determined, for as yet sufficient time 
has not elapsed to form judgment. Sixteen 
operations have been reported with but one 
death. The almost unanimous conclusion of 
those who have performed the operation is in 
its favor. 
Gastropexy is the name applied to the operation 
of suturing the stomach to the anterior abdominal 
wall. The operation has been performed for the 
relief of gastroptosis or sagging of the stomach, 
which is with difficulty distinguished from dilata- 
tion. The condition present is usually one of 
general visceral ptosis, hence the operation is 
commonly futile (Binnie). 
Gastroplasty, Gastroanastomosis, and Gastro- 
gastrostomy are performed for hour-glass stomach. 
In gastroplasty a longitudinal incision is made in 
the constricted portion between the two pouches 
of hour-glass stomach; the incision is stretched at a 
right angle, and sutured as in the Heineke- 
Mikulicz operation of pyloroplasty. The opera- 
tion has been performed successfully in 7 cases. 
In gastrogastrostomy an opening is made in each 
of the two gastric pouches, and a free communica- 
tion is established between them by anastomosis 
of the two openings. The operation has been 
performed in 5 cases with 1 death. Gastro- STOMACH, ULCER 
STOMACH, ULCER 
anastomosis has also been successfully performed 
by Watson, as follows: The pouches were folded 
over on the constricted portion between the two 
as a hinge; the anterior wall of the stomach was 
incised, to give access to the double septum be- 
tween the pouches; an opening was made in this 
double septum and sutured, and the incision in the 
anterior stomach-wall was closed. This method 
would be impossible if there were adhesions fixing 
either pouch. 
The three operations seem equally successful, 
and the one selected would depend upon the 
mechanic conditions of each case. Hour-glass 
stomach may be congenital, but usually does not 
develop until adult life. The most common cause 
is adhesions following gastric ulcer. It is with 
great difficulty that a differential diagnosis can 
be made between this condition and obstruction 
due to pyloric stenosis. If severe disturbances 
of digestion arise, as is often the case, one of 
these operations would be indicated. 
Surgical Treatment of Gastric Ulcer.-See 
Stomach (Ulcer). 
Gastrectomy.-The operation may be either 
partial or complete. In partial gastrectomy, only 
a portion of the stomach-wall is removed; pylo- 
rectomy is an example of partial gastrectomy. 
This operation is indicated in cases of tumors of 
the stomach and in certain perforating or perfo- 
rated gastric ulcers. Complete gastrectomy is the 
removal of the entire stomach. It has been 
believed possible to distinguish between the 
epithelial layers of the mucous membrane of the 
esophagus and of the stomach, but recent investi- 
gations seem to indicate that no well-marked 
boundary-line exists, so it is difficult to say abso- 
lutely when the entire organ is removed. Suffi- 
ciently extensive operations to deserve the name of 
total gastrectomy have been performed in 10 cases, 
with 4 recoveries from the operation. Two of 
these • patients have since died from recurrence 
of the growth. 
Indications.-The operation may perhaps be con- 
sidered indicated in case of extensive malignant 
growths of the stomach which have not caused 
metastasis or become extensively adherent to 
neighboring organs, but the operation should 
certainly be performed only in the rarest and 
most unusually favorable cases, by surgeons of 
exceptional skill and wide experience in abdominal 
surgery. 
STOMACH, ULCER. Synonyms.-Peptic ulcer; 
simple or round ulcer; gastric ulcer. 
Etiology.-(1) Traumatism; (2) hemorrhagic 
infiltrations; (3) hyperacidity; (4) anemia; (5) 
heart-disease; (6) nephritis; (7) chronic catarrh. 
Both gastric and duodenal ulcers result from the 
same causes. 
Pathology.-Generally, the ulcerative spot is 
round in contour and is situated on the posterior 
wall of the lesser curvature of the stomach. The 
edges are usually clean-cut, and from above down- 
ward are cone-shaped, with the base resting on 
the peritoneal coat of the organ. In some 
instances a perforation occurs, leaving a " punched- 
out" appearance. The duodenal ulcer is usually 
situated at the upper portion of the bowel. In 
many cases there is a series of ulcers scattered over 
the mucous membrane of the stomach. 
Symptoms and Clinical Course.-There are 
localized pain, vomiting, hematemesis, gradual 
loss of flesh and strength, dyspepsia, grave 
anemia, and excessive secretion of hydrochloric 
acid. The hemoglobin may be reduced to 50 per- 
cent and the red cells are proportionately de- 
creased. The leukocytes in some cases are de- 
creased; other cases show leukocytosis. 
The pain is very characteristic, being always 
localized and made worse by pressure or ingestion 
of. food. It is of a burning, sharp, or acute 
character. 
Hematemesis is possibly the most marked objec- 
tive symptom of the disease. It may come on 
either while taking violent exercise or during the 
period of rest, and has occurred during the night 
hours. Hematemesis occurs in about 50 percent 
of the cases of gastric ulcer. 
Complications.-(1) Perforation, giving rise to 
peritonitis; (2) death from hemorrhage, perfora- 
tion, or exhaustion; (3) cicatricial contraction, 
causing obstruction. 
Diagnosis.-See Gastritis (Chronic). 
Prognosis is guardedly favorable. 
Treatment.-For the first few weeks after the 
ulcer has been detected absolute rest in bed 
should be enjoined, and only a liquid diet allowed. 
In most cases, perhaps, it is best to give the food by 
the rectum for the first few days, continuing as 
long as the digestive powers maintain the strength 
of the patient. 
Rectal Alimentation.-Before giving a nutritive 
enema the bowels should always be irrigated with 
a quart of lukewarm water, or normal saline 
solution, given as a high enema. Peptonized 
milk is the best nutrient (Tyson). 
Boas recommends the following nutritive 
enema: 8 ounces of milk; the yolks of 2 eggs; 
1 dram of sodium chlorid; 1 ounce of claret wine; 
and a tablespoonful of aleuronat flour. These 
ingredients to be thoroughly beaten together, 
subsequently warmed for a few minutes at a 
temperature of 99° F., and then slowly injected 
by means of a fountain syringe. 
Ewald recommends the following: From 3 to 5 
eggs are beaten up with 5 ounces of a 15 percent 
solution of glucose, to which a small amount of 
starch-water has been added. Also this: Boil flour 
(1/2 dram) in half a cupful of a 20 percent solution 
of glucose and add a wine-glassful of claret. To 
this are afterward added 2 or 3 eggs, well beaten 
in a tablespoonful of water. 
Later in the treatment milk may be given by the 
mouth, together with a small amount of soup made 
from beans or potatoes. No solid food should be 
given for at least 3 weeks from the time the disease 
is diagnosed, and then only the lightest articles of 
diet. 
Hematemesis.-Absolute rest must be enjoined, 
the patient not being allowed to sit up to take food 
or medicine or to defecate or urinate. If possible 
neither solids nor liquids should be given by the 
mouth for at least 2 days. To assuage thirst, the STOMACH, ULCER 
STOMACH-CONTENTS, EXAMINATION 
lips and tongue may be sponged off with ice- 
water containing a very small amount of 
glycerin. 
An ice-bag or cloths dipped in ice-water or the 
ice-coil may be placed over the affected area. 
Pieces of ice may be swallowed. Copious enemata 
of hot water are advocated by Tripier. If the 
hemorrhage is severe, ergotol (20 minims) may be 
given hypodermically, together with morphin (1/4 
grain). At the present time, however, preference 
is given to adrenalin chlorid in repeated doses of 
10 drops of the 1 to 1000 solution, given in 1 dram 
of water. 
Two weeks after the hemorrhage has occurred, 
Fox recommends the best treatment, a glass of 
laxative mineral water daily, with a light diet, 
and hot applications to the epigastrium. Nitrate 
of silver (1/4 grain) may be taken in a glass of 
water before meals. 
Bismuth sub nitrate in doses of 90 to 120 grains 
daily has proved most efficient in promoting 
healing of the ulcer. Local applications may 
relieve the pain; morphin should be avoided if 
possible. 
The Lenhartz Treatment.-The patient is put to 
bed for 3 to 4 weeks and for the first 2 weeks is 
given a diet rich in albumen. Ice-cold food is 
given slowly by the mouth in small amounts at 
short intervals, beginning with 2 drams of egg and 
4 drams of milk every hour for the first day, the 
intervals being 1 hour from 7 A. M. to 9 p. m. for 
the first 10 days. Lembert has suggested feeding 
the mixture of egg and milk, instead of each 
singly every hour, and adding sugar after the third 
day. For the effects of hemorrhage, enterocylsis 
is practised, and iron and arsenic are given for the 
anemia. 
Surgical treatment may be indicated in non- 
perforating or in perforating gastric ulcers. 
The more remote effects of gastric ulcer have been 
discussed and their treatment has been considered 
under gastrolysis, gastroenterostomy, pyloroplasty, 
resection of the stomach, and the operations for 
hour-glass contraction of the stomach. See 
Stomach (Surgery). Acute perforating ulcer 
indicates operation in case of dangerous and 
repeated hemorrhage, extremely severe pain, 
and intractable vomiting and indigestion; or when 
there is a suspicion of malignant degeneration. In 
such cases the ulcer may either be excised and the 
gastric wall sutured, or gastroenterostomy or 
pyloroplasty may be performed to put the ulcer 
at rest. Gastroenterostomy has been combined 
with excision in certain cases, with advantage. 
Perforated Gastric Ulcer.-Usually, perforation 
occurs very suddenly, without any apparent 
cause, although violent exertion or traumatism 
has sometimes been the immediate cause. There 
is intense pain, generally localized in the left 
hypochondrium; there may be nausea and vomit- 
ing, perhaps vomiting of blood; soon after this 
symptoms of peritonitis set in; the abdomen 
becomes distended, tympanitic, and tender; and 
liver dullness is obliterated. The other consti- 
tutional symptoms develop as the peritonitis 
progresses. 
Treatment.-All food should be withheld and 
preparations should be made for immediate 
operation. The incision may be made in the 
median line above the umbilicus or to the left 
of the median line. When the diagnosis is abso- 
lutely certain, the incision may be made with 
advantage parallel to the border of the ribs, as a 
large proportion of gastric ulcers perforate near 
the cardia and lesser curvature. A careful search 
should be made, first of the anterior wall of the 
stomach, beginning near the cardia, taking next 
the pylorus, and, finally, the posterior wall, the 
positions named being given in order of the 
relative frequency of perforation. The edges of 
the ulcer are inverted and the stomach-wall is 
sutured by one or two rows of Halsted or Lembert 
sutures. Great care should be taken that the 
entire ulcer is inverted, and careful search should 
be made for a second perforation or for a threatened 
perforation. Needless fatalities have resulted from 
the neglect of both of these precautions. If it is 
impossible to invert the edges of the ulcer, they 
may be brought into contact by suture, as if a 
cutaneous wound were being dealt with; and in 
case of possible insecure suture, the application 
of an omental graft would be an additional safe- 
guard. If neither of these procedures is possible, 
the abdominal cavity may be walled off by iodo- 
form gauze and a tube may be introduced down 
to the ulcer. The fistula that will result usually 
closes spontaneously or it may be closed later by 
a plastic operation. Great care should be taken 
in cleansing the peritoneal cavity. It should be 
thoroughly flushed with warm sterile salt solution 
and any suspicious spots wiped clean; if necessary, 
counteropenings may be made, and it is usually 
desirable to drain, not only at the seat of operation, 
but also from the pelvis. Success depends mainly 
upon early diagnosis and operation; patients oper- 
ated upon within 12 hours from the time of perfo- 
ration have excellent prospects for recovery, the 
mortality being only about 16 percent since 1896. 
Other features of importance are the amount of 
food contained in the stomach at the time of 
perforation, the condition of the patient, and the 
skill of the operator. A few years ago the mor- 
tality in a series of cases carefully collated was 
about 53 percent. Moynihan has recently esti- 
mated it to be from 35 to 40 percent. 
STOMACH-CONTENTS, EXAMINATION.-For 
purposes of examination, the contents of the 
stomach should be obtained through the stomach- 
tube, as vomited contents contain so much buccal 
and esophageal mucus that the examination is 
rendered difficult and imperfect. See Lavage. 
The gastric contents are examined as to color, 
amount, odor, consistency, individual food ele- 
ments present and their state of disintegration and 
solution; also as to the presence of mucus, blood, 
pus, fragments of mucous membrane, or foreign 
bodies. This macroscopic investigation is fol- 
lowed by chemic analysis and microscopic 
examination. 
Test-meals.-The contents are usually examined 
after a test-meal. One of the following test-meals 
is usually employed: STOMACH-CONTENTS, EXAMINATION 
STOMACH-CONTENTS, EXAMINATION 
1. Ewald-Boas test-breakfast consists of 1 or 2 
rolls and a cup of water. The examination is 
made 1 hour after eating. 
2. Leube-Riegel test-dinner consists of soup, 
meat, potato and roll. Examination is made 3 or 
4 hours afterward. 
3. A meal consisting of 1 or 2 broiled finely 
chopped beef-balls, 1 or 2 ordinary slices of dry 
stale bread, and a cup of water (hot or cold). 
This is eaten at 9 o'clock in the morning, and the 
stomach is examined at 12 o'clock noon. No 
breakfast is allowed before 9 o'clock in the 
morning. 
If possible, the stomach-contents are obtained 
undiluted, a feat quite readily accomplished by 
the Ewald expression method, which consists of 
voluntary contraction of the patient's diaphragm 
and abdominal muscles, thereby compressing the 
stomach and forcing a portion of the contents 
upward through the tube. Usually from 40 to 100 
c.c. are thus obtained, and then filtered, and ex- 
amined for hydrochloric acid. Before filtration, 
however, the contents may be tested for free 
acid by Congo paper, which changes from red to 
blue. 
The chief tests for free hydrochloric acid are 
Gunzburg's, Boas', and Toepfer's. 
Gunzburg's reagent is composed of phloroglucin 
(2 gm.), vanillin (1 gm.), and absolute alcohol 
(30 c.c.); it is unnecessary to use absolute alcohol, 
as ordinary pure alcohol will do as well. This 
solution is changed by the light, and should be 
kept in a colored-glass bottle. A porcelain capsule 
is overlaid with gastric filtrate, and 3 or 4 drops of 
the reagent added; the capsule is agitated to insure 
thorough mixture, and evaporated to dryness 
slowly over a Bunsen burner or an alcohol lamp. 
In the presence of free hydrochloric acid a beautiful 
rose-red color appears. 
Boas' reagent consists of resorcin (5 gm.), white 
sugar (3 gm.), and alcohol (100 c.c.), and gives, 
with free HC1, a bright-red color, the test being 
conducted in the same manner as with the phloro- 
glucin vanillin solution. 
Toepfer's reagent is a 0.5 percent alcoholic solu- 
tion of dimethylamidoazobenzol. It must be kept 
in a colored bottle. In the presence of free HC1 it 
strikes a bright cherry-red without the use of heat. 
To 5 c.c. of the gastric filtrate add 1 or 2 drops of 
the reagent, and the whole turns red. This is a 
delicate, convenient, and valuable test, and is 
quickly made. It reacts to large (unusual) amounts 
of lactic or other organic acid, but in ordinary work 
this objection has no force. Friedenwald thinks 
highly of the test; Einhorn considers it somewhat 
unreliable; Hemmeter gives it front rank; and by 
others it is valued greatly. 
Not only is Toepfer's reagent useful in the quali- 
tative detection of free HC1, but also its quantita- 
tive estimation. Thus 10 c.c. of the gastric filtrate 
reddened by the addition of the reagent are treated 
by a decinormal sodium hydrate solution from a 
buret until the red gives place to a yellow color, 
and the number of cubic centimeters of soda 
solution required to neutralize the free HC1 is 
taken as the multiplier of 0.00365. For example, 
3 c.c. of soda solution are used and 0.00365X3 = 
0.1095 percent. 
For the determination of the amount of free 
HC1, organic acids, and acid salts, a 1 percent 
aqueous solution of alizarin may be used. To 
10 c.c. of the gastric filtrate add 1 or 2 drops of 
the alizarin solution, and neutralize with deci- 
normal sodium hydrate solution; a violet color 
results. 
It is important to know the total acidity of the 
gastric contents, which is obtained as follows: 
To 10 c.c. of the gastric filtrate add 1 drop of the 
1 percent alcoholic solution of phenolphthalein, 
and neutralize with decinormal sodium hydrate 
solution added slowly from a buret; a cherry-red 
color results. The number of cubic centimeters 
of sodium hydrate solution required to neutralize 
10 c.c. of gastric filtrate is expressed as if 100 c.c. 
of the filtrate were used. The normal total acidity 
after a test-breakfast is from 40 to 65 percent- 
i. e., 4 to 6.5 c.c. of soda solution are required to 
neutralize 10 c.c. of the gastric filtrate. 
Lactic Acid.-For the detection of lactic acid 
Uffelmann's test is commonly used: Ten c.c. of a 
4 percent solution of carbolic acid are diluted with 
20 c.c. of distilled water, and 1 drop of ferric 
chlorid solution is added, which gives rise to an 
amethyst-blue color. The gastric filtrate is added, 
and if lactic acid is present, a canary-yellow color 
is produced. Alcohol, phosphoric acid, and 
glucose also give the reaction. 
Butyric Acid.-Fatty acids may usually be 
detected by the odor. As they are volatile, the 
vapor arising from a test-tube in which the gastric 
filtrate is boiling reddens blue litmus paper held at 
the mouth of the tube. 
Acetic acid may be detected by its odor, but 
it is better to extract with ether, evaporate, make 
an aqueous solution of the residue, neutralize 
with soda solution, and add a weak ferric chlorid 
solution, which gives a dark red color if acetic 
acid is present. 
The Digestion of Proteids.-The hydrochloric 
acid of the gastric juice combines with albumin- 
oids to form first syntonin or acid albumin. 
Pepsin hydrochloric acid digestion then results 
in the formation of proto- and heteroalbumose. 
Following this change deuteroalbumoses are 
formed, and, finally, peptones. These albumoses 
are grouped under the name of propeptone, and 
though by elaborate tests they may be separated 
and differentiated, it suffices that propeptone is 
precipitated by adding an equal part of a saturated 
solution of sodium chlorid and acidulating with 
acetic acid; it dissolves on heating, and precipi- 
tates again on cooling. Peptone yields a purplish- 
red color upon the addition of Fehling's solution 
to the filtrate, as also does propeptone. 
Rennet Ferment.-Add about 4 drops of the 
filtrate to 5 c.c. of fresh milk, and place in warm 
water (100° F.). In 15 minutes coagulation 
should take place. In case the milk is not 
curdled in half an hour, add 2 or 3 drops of a 1 
percent solution of calcium chlorid, and if coagula- 
tion takes place, it indicates the presence of 
rennet zymogen. STOMATITIS, APHTHOUS 
STOMATITIS, GANGRENOUS 
Starch Digestion.-The action of saliva upon 
starchy foods is continued in the stomach to the 
formation of erythrodextrin, achroodextrin, and 
maltose. Tested with Lugol's solution, erythro- 
dextrin strikes a reddish-brown color, while 
achroodextrin and maltose give no color change. 
The microscopic examination of the gastric con- 
tents is important. In cases of hyperchlorhydria 
unchanged starch granules are often present in 
large numbers; while in cases of deficient gastric 
secretion undigested muscle-fibers are more 
numerous than under normal conditions. With 
benign pyloric stenosis, gastrectasia, and food 
stagnation, sarcinse and yeast-cells are often 
found. They may be stained with methyl-blue, 
which also stains the so-called "Faden" bacillus 
-the Oppler-Boas bacillus-found with carcino- 
matous pyloric stenosis, and so significant of the 
disease. This is a very long, delicate, thread-like 
bacillus. Sarcinae and yeast-cells are also found 
in the stagnating contents of carcinoma ventric- 
uli, but not so frequently as in benign stenosis. 
Pus-cells are rarely found. Red blood-cor- 
puscles may be present. Mucus, epithelium, 
and mucus-corpuscles are commonly seen, especi- 
ally in gastric catarrh. Many bacteria are 
present, among which may be a number that 
give rise to the formation of lactic acid. Small 
fragments of mucous membrane are sometimes 
found in the washings from the stomach, and 
they have been especially studied by Boas, 
Einhorn, and others. They have been found 
in cases of gastric erosion. They should be 
hardened, stained, and mounted, as atrophy of 
the glands or mucoid or cancerous degeneration 
may thus be discovered. 
STOMATITIS, APHTHOUS (Herpetic Stomatitis; 
Vesicular Stomatitis).-This form of stomatitis is 
more common than the simple catarrhal form. 
It is characterized by a hyperemia of the mucous 
membrane of the mouth, and by the formation 
upon it of small, yellowish-white vesicles of a 
herpetic character. Children from 6 to 18 months 
of age are the most commonly affected. 
Etiology.-The direct cause is uncleanliness of 
the mouth, improper and poorly prepared food, 
and dentition. The predisposing causes are 
malnutrition, unhygienic surroundings, digestive 
disturbances, and the tubercular diathesis. 
Symptoms.-Quite characteristic symptoms are 
noticed in this affection. The child is dull, fretful, 
and feverish, does not wish to be disturbed, and 
refuses nourishment. The mouth is hot and 
painful, and the saliva, running over the chin and 
neck, causes these parts to be irritated. On 
inspecting the mouth, small vesicles are found 
under the tongue, on the gums, or upon the inner 
side of the lips. The vesicle soon disappears, but 
a small shallow ulcer remains for 4 or 5 days. 
These herpetic spots may be discrete or diffuse, 
covering more or less of the mucous membrane. 
Treatment.-This affection is evidently self- 
limited. Recovery without treatment, as a rule, 
would probably take place in the course of a week 
or 10 days. As recommended in catarrhal sto- 
matitis, however, in all cases the diet should be 
carefully regulated, the bowels gently acted upon 
with a laxative, the hygienic conditions, if faulty, 
improved, and the mouth and the nursing-bottle 
kept clean. In any form of stomatitis the follow- 
ing is an excellent mouth-wash: 
I|. Salicylate of sodium, 3 ij 
Water, J j. 
Apply 5 or 6 times a day. 
If the ulcers heal slowly, they should be touched 
with a stick of nitrate of silver. 
STOMATITIS, CATARRHAL.-A simple catar 
rhal inflammation of a portion or of the entire 
surface of the mouth. It occurs most commonly 
during the period of first dentition. 
The causes are uncleanliness of the mouth and 
of the nursing-bottle, etc., the ingestion of 
irritating or overheated food, and the eruption of 
the teeth. It may be secondary to gastrointes- 
tinal disturbances or to the exanthems. 
Symptoms.-The mouth is red and is at first 
dry and hot; later, there is an increased salivary 
flow, which becomes acid and excoriates the skin 
around the mouth as it is dribbled. The tongue 
is coated, and the child is restless, feverish, and 
thirsty; the appetite is diminished, and the bowTels 
usually are constipated. 
Sucking causes pain, which is shown by the fact 
that the child drops the nipple with a cry as soon 
as its hunger is partly satisfied. The course of 
this form of stomatitis is usually acute, an attack 
lasting about a week. 
Treatment.2-Attention to the proper hygiene 
of the mouth will usually prevent it from becoming 
sore. The nursing-bottle and nipple should be 
kept scrupulously clean; the fingers should not 
be introduced into the child's mouth before being 
thoroughly cleansed; and, before and after feed- 
ing, the infant's mouth should be washed with 
plain boiled water or with borax and water on a 
clean, soft cloth. Careful regulation of the diet, 
a mild laxative, such as small doses of calomel 
(1/12 grain every 2 hours) or calcined magnesia 
(10 or 20 grains); and a mild alkaline mouth-wash, 
such as the following, will usually be sufficient 
to cure the condition: 
3. Borax, 3 j 
Glycerin, 3 ij 
Rose-water, g ij. 
Use every 1 or 2 hours with .a swab, gently 
washing the mouth. (Older children will 
be able to wash their mouths without the 
swab.) 
STOMATITIS, GANGRENOUS (Noma; Can- 
crum Oris).-A rare affection, consisting of a gan- 
grenous destruction of the tissues of the cheek, 
and possibly of the adjoining structures as well. 
Etiology.-It is supposed to be microbic in 
origin. The most frequent predisposing causes 
are the exanthems or any disease which leaves 
the child weak and debilitated. In nearly all 
cases it is seen in those who are subjected to the 
worst possible hygienic and sanitary surroundings. 
Symptoms.-There will be noticed at first an 
inflamed spot on the inside of one cheek near the STOMATITIS, PARASITIC 
STOVAIN 
corner of the mouth. This spot is at first hard, but 
soon ulcerates, and the cheek becomes swollen and 
edematous. From the first the breath has a gan- 
grenous odor, and later the fetor becomes intense. 
The gangrenous process spreads rapidly, perfor- 
ating the cheek, and death will be caused by septic 
pneumonia or by a general systemic poisoning. 
Many cases die as early as the first 3 or 4 days, 
while others linger 2 or 3 weeks; recovery is 
extremely rare. 
Treatment.-Strict cleanliness of the mouth in 
children whom debilitating diseases render liable 
to this affection is of prophylactic importance. 
When the gangrenous condition has commenced, 
however, the only treatment that offers any hope 
is free excision of the affected areas. 
STOMATITIS, PARASITIC (Thrush).-An affec- 
tion of the mouth characterized by a catarrhal 
condition and by the presence on the mucous mem- 
brane of white, flake-like patches. It occurs 
usually in young infants, and is caused by a 
vegetable parasite (one of the mold fungi) variously 
known as oidium albicans or saccharomyces 
albicans. 
Etiology.-Uncleanliness of the mouth, giving 
rise to acid fermentation, is the principal indirect 
cause. It may be transmitted from one child 
to another by the nursing-bottle, spoons, etc. 
Dirty nipples and long nursing-tubes offer a 
fertile soil for the propagation and growth of the 
parasites. 
Symptoms.-The fungus appears on the inside 
of the lips, on the gums, tongue and hard and soft 
palates, and may be limited to a small area of these 
parts or may extend to the pharynx or esophagus. 
It is white or gray in color, and has the physical 
appearance of curdled milk, for which, upon 
superficial examination, the spots might be mis- 
taken; it will be found, however, that they are 
adherent to the mucous membrane. 
The general symptoms are those of catarrhal 
stomatitis, by which it is accompanied. Micro- 
scopic examination of the deposits will make 
the diagnosis certain, if any doubt exists. 
Treatment.-Absolute cleanliness of the child's 
mouth, and of the feeding apparatus and every- 
thing that may be brought in contact with it, 
is essential. 
The diet must be appropriate and carefully 
regulated and prepared, and the general hygienic 
conditions must be made as good as possible, as 
this is essentially a filth disease. The mouth 
should be carefully washed every 1 or 2 hours 
when the child is awake, and before and after 
each feeding. The cloths that have been used to 
wash the mouth should be burned, and care 
should be taken to keep all articles that may 
have been in the mouth away from other children, 
as thrush may be conveyed from one to another. 
The following formula is an efficient mouth- 
wash for this condition: 
1$. Listerine, 5 j 
Dobell's solution, 5 ij. 
Dilute with an equal quantity of water and 
wash the mouth frequently. 
STOMATITIS, UICERATIVE.-This form of sto- 
matitis consists of an inflammation and ulceration 
of the mucous membrane of the gums principally, 
though the tongue and cheeks may also be affected. 
It may occur at any time after dentition com- 
mences, but is most common between the ages of 
3 and 10 years. 
Etiology.-Ulcerative stomatitis is a prominent 
symptom of infantile scorbutus; it is also seen 
following the acute infectious diseases, and it is 
caused by salivation from the administration of 
mercury. Unhygienic conditions, malnutrition, 
etc., are common predisposing causes. 
Symptoms.-Constitutional symptoms, such as 
slight fever, restlessness, anorexia, and thirst are 
usually present. The edge of the gums over the 
teeth-usually the lower incisors-is first seen to 
be reddened and swollen. The pain and saliva- 
tion are more marked than in aphthous stomatitis, 
and the saliva is acrid, irritating, and of an offensive 
odor. The mucous membrane soon becomes 
purplish in color, spongy, and congested, and 
hemorrhages from it occur on the slightest pressure. 
The tongue is coated, the breath foul, the appetite 
lost, and the child rapidly becomes weak and 
emaciated. Under favorable conditions and proper 
treatment the affection usually disappears in 1 or 
2 weeks. When caused by a cachectic condition 
or by constitutional disorders, such as scorbutus, 
the course will be governed by these conditions. 
In protracted cases the ulcerations may become 
gangrenous, and necrosis of the jaw may ensue. 
Treatment.-The sanitary surroundings should, 
if faulty, be improved, and fresh air and sunlight 
are essential. Nourishing liquid diet should be 
given, and cool drinks to satisfy the thirst. If 
there is any constitutional disease that is the pos- 
sible cause of the stomatitis, it should be 
properly treated. 
Chlorate of potassium is a specific in this form of 
stomatitis. It should be given internally (as it is 
eliminated by the salivary glands) and as a mouth- 
wash. A child under 1 year of age may safely 
be given from 10 to 20 grains in the course of 24 
hours, and it is best given in small doses, frequently 
repeated. A convenient method of administering 
this remedy is to dissolve 1 dram in half a glass 
of water, giving from 1/2 to 2 teaspoonfuls, 
according to the child's age, every 1 or 2 hours. 
The mouth should be frequently washed with the 
same solution or with a solution of borax or 
salicylate of sodium. A teaspoonful of dioxid of 
hydrogen to the ounce of water also makes 
an effective wash. 
STONE.-See Bladder (Stone), Gall-bladder 
(Diseases), Kidney (Stone). 
STOOL.-See Feces. 
STOV AIN.-Benzoylethyldimethylaminoprop- 
anol hydrochlorid. It is more stable than 
cocain, and is less than one-half as toxic as 
cocain, though equally powerful as an anesthetic, 
and has the great advantage of being a vaso- 
dilator, cocain being a vasoconstrictor. As a 
substitute for the latter it is used with great 
satisfaction for local and spinal anesthesia. 
Locally it may be used in the eye in 4 percent STRABISMUS 
STUMP 
solution and applied to other mucous membranes, 
in 5 to 10 percent solution. For hypodermic 
injections for local anesthesia it can be used in 
0.75 to 1 percent solution. For spinal injection, 
1/2 to 5/8 of a grain is used (Babcock) in the 
spinal fluid, the alkalinity of which necessitates 
the addition of sodium chlorid in the proportion 
of 5 percent. See Intraspinal Anesthesia. 
STRABISMUS.-See Eye-muscles. 
STRAMONIUM (Thorn-apple).-The dried 
leaves of Datura stramonium, the well-known 
Jamestown or jimson-weed. It contains the 
alkaloids atropin and hyoscyamin, also some 
hyoscin, and a volatile oil containing daturic acid. 
Daturin. is the name of the mixed alkaloids. 
Dose, 1/2 to 3 grains. See Belladonna. It has 
the general properties of belladonna, but is more 
powerful. Stramonium has held a high position 
as a local remedy in spasms of the glottis and in 
asthma. The smoke from the burning leaves may 
be inhaled. A convenient means of using it is to 
draw the fumes into the lungs through a pipe filled 
either with the pure leaves or with a mixture of 
the same with tobacco. The impression is ordi- 
narily combined with that of nitrate of potassium. 
The effect should be carefully watched, since the 
poisonous properties of the drug may easily be 
induced. The smoke from about a half ounce of 
the leaves may be inhaled at a single sitting. The 
number of sittings is determined by the attendant 
circumstances. A sensation of heat in the lung, 
of fulness about the head, or of nausea is an indi- 
cation that a maximum has been reached. 
Preparations.-S., Ext. Dose, 1/8 to 1/2 grain. 
S. Flext. Dose, 1/2 to 3 minims. S., Tinct., 10 
percent strong. Dose, 5 to 15 minims. S., Ung., 
contains of the extract 10, water 5, benzoinated 
lard 85 parts. Daturin is the alkaloid. Dose, 
1/200 to 1/80 grain. 
STRANGULATION.-See Asphyxia, Hernia, 
Intestinal Obstruction, Neck (Injuries). 
STRANGURY.-Painful, scanty urination. It 
is a most prominent feature of poisoning by 
turpentine or cantharides, being induced even by 
the action of a blister. In various inflammatory 
conditions and morbid growths of the bladder and 
prostate gland it is also present, and is a constant 
symptom of acute posterior urethritis. 
Treatment.-As a rule, hot baths and morphin 
are the most efficacious remedies. Free saline 
purging and the administration of belladonna are 
recommended. Barley-water, effervescing waters, 
milk, and other bland drinks are to be freely taken 
when the attack exists. Thirst may be slaked by 
iced drinks. 
If there is overdistention of the bladder, 
catheterization may be necessary. See Urine 
(Retention). 
STREPTOCOCCUS.-See Serum Therapy; 
Suppuration; Vaccine Therapy. 
STRICTURE.-See Esophagus (Stricture), Rec- 
tum (Stricture), Uretha (Stricture), etc. 
STRIDOR.-A peculiar, harsh, vibrating sound 
arising from some obstruction in the throat or in 
the larger respiratory tubes. It is most commonly 
due to compression of the trachea by some ex- 
traneous growth, or to spasm or paralysis of the 
vocal bands. 
STROKE.-See Brain (Hemorrhage), Heat- 
stroke. 
STRONTIUM.-This metal is represented in 
medicine by its salts, the bromid, iodid, salicylate 
(see Bromin, Iodin, Salicylic Acid) and the 
lactate. They are believed to be much less 
irritating to the stomach and less prone to cause 
eruptions than the sodium and potassium salts, 
though at the same time they are less powerful 
than the latter. Elimination, too, is more rapid 
and more complete. 
The lactate in doses of 5 to 30 grains has been 
successfully employed in diabetes and in albumin- 
uria. It diminishes the amount of albumin in 
Bright's disease, in the parenchymatous nephritis 
of rheumatic and scrofulous subjects, and in the 
albuminuria of pregnancy; for which purpose it 
should be given in full doses (gr. xxx) thrice daily. 
It is contraindicated when there is scanty urine or 
symptoms of uremia. 
STROPHANTHUS.-The ripe seed deprived of 
its long awn, of Strophanthus Kombe, an African 
climbing plant from which the natives extract a 
toxic preparation known as the Komb6 arrow- 
poison. It contains a crystalline glucosid, named 
strophanthin, the active principle, which is an 
agent of great energy, the frog being killed by a 
solution of 1 part in 10,000,000. Dose of stro- 
phanthus, 1 /2 to 2 grains. In medicinal properties 
it closely resembles digitalis, producing loss of re- 
flex sensibility and of voluntary motion, but not 
causing contraction of the arteries to the same 
degree. Strophanthus is undoubtedly a valuable 
cardiac stimulant, from the rapidity and per- 
manence of its action, as well as from its non- 
interference with the caliber of the peripheral 
vessels. It promptly relieves cardiac dyspnea, 
often modifies the pulse-rate in less than an hour, 
while the influence of a single dose upon the cir- 
culation persists for a long time. It may replace 
digitalis in the treatment of chronic nephritis and 
valvular lesions of the heart, when it is important 
that the work of the heart should not be increased 
by any additional resistance in the arterial system. 
It has been reported as useful in the treatment of 
dyspnea, orthopnea, dropsy, and uremia, also in 
mitral insufficiency, with great anasarca and 
dyspnea; in palpitation, exaggerated cardiac 
action, and in weak heart, and for exophthalmos, 
with tumultuous action of the heart; also in pul- 
monary edema, due to valvular lesions or to pneu- 
monia. It is useful in endocarditis, also in 
atheroma of the arteries; in reflex palpitation of 
neurasthenia, hysteria, and chlorosis, and for 
rigors due to catheterization or operations on the 
urethra. Dose of the tincture, 5 to 10 minims; 
of strophanthin, 1/300 to 1/100 grain. 
STRUMA.-See Scrofula. 
STRYCHNIN.-C21H22N2O2. A poisonous alka- 
loid in the fruit of Strychnos nux vomica and found 
in St. Ignatius' bean. It crystallizes in four-sided 
prisms, melting at 284° C., and possessing an 
extremely bitter taste. See Nux Vomica. 
STUMP.-See Amputation. STUTTERING 
SULPHONAL 
STUTTERING.-See Speech Defects. 
STYE (Hordeolum).-A furuncular or phleg- 
monous inflammation near the hair follicles or 
margin of the fid. Eye-strain is a common cause. 
Symptoms.-It begins with a pricking pain, soon 
followed by swelling of the affected lid. A tender, 
hard spot is easily located by palpation, and may 
be inspected by raising the lid away from the eye- 
ball, when a yellowish point will be seen. 
Treatment.-If pus is seen, it should be released; 
and, as a rule, the symptoms will usually imme- 
diately subside. The pointing of the stye is 
hastened by the application of hot compresses for 
15 minutes every 2 hours. To prevent recurrence, 
cleanliness and disinfection with a lukewarm 
bichlorid solution (1:5000) are demanded. A 10 
percent sulphur ointment may be used. Recur- 
rence of styes is suggestive of refractive error or 
of constitutional disorder, and the ametropia 
should be corrected and the general health im- 
proved. 
STYPTICIN.-The hydrochlorid of cotarnin, 
a base produced by the oxidation of narcotin. It 
has been used with good results as a styptic and 
sedative in a number of cases of uterine disease, 
the dose being from 1 to 5 grains by mouth or 
hypodermically, four or five times a day. 
STYPTICS.-See Hemostatics and Styptics. 
STYRACOL.-Guaiacol cinnamate. Styracol is 
an intestinal antiseptic and is claimed to combine 
the antituberculous actions of guaiacol and cin- 
namic acid. It is said to liberate in the intestinal 
canal a larger proportion of its guaiacol (up to 85 
percent) than other synthetic preparations of 
that substance. Dose, 15 grains. 
STYRAX (Storax).-A balsam obtained from 
the wood and inner bark of Liquidambar orientalis, 
or oriental sweet-gum. It contains a volatile 
oil (styrol), a crystalline solid (styracin), several 
resins, and cinnamic acid. It is a stimulant 
expectorant, an antiseptic, and disinfectant, acting 
like benzoin and tolu, and is used in bronchial 
affections and in catarrh of the urinary passages. 
Externally, it is an antiseptic and parasiticide. It 
is a constituent of Friar's balsam. Dose, 5 to 20 
grains. 
SUBARACHNOID INJECTION.-See Intra- 
spinal Anesthesia. 
SUBINVOLUTION.-Failure or delay on the 
part of the uterus to return to its normal condition 
after labor. See Involution. 
SUBLAMIN.-A combination of mercuric sul- 
phate and ethylene diamin, containing 43 percent 
of mercury. It is insoluble in alcohol, but freely 
soluble in water, and is used in 1:500, or 1:1000 
solution for disinfecting hands and instruments. 
SUBLIMATE.-See Mercury. 
SUBMERSION.-See Drowning. 
SUBUNGUAL EXOSTOSIS.-See Nails (Dis- 
eases). 
SUCCUSSION.-The shaking of the individual 
from side to side for the purpose of determining 
the presence of fluid in a cavity or hollow organ of 
the body. The succussion sound or splash is the 
peculiar splashing sound heard in hydropneumo- 
thorax or pyopneumothorax when the patient's 
chest is slightly shaken. It is due to the combined 
presence of air and fluid in a closed cavity. It was 
first described by Hippocrates, and hence is also 
known as the "Hippocratic sound." The sound 
may also be obtained in the presence of a dilated 
stomach partly filled with fluid. See Chest 
(Examination). 
SUDAMEN.-See Sweat Glands. 
SUDDEN DEATH.-See Death (Sudden). 
SUDORIFIC.-See Diaphoretics. 
SUFFOCATION.-See Asphyxia. 
SUGAR.-See Diabetes, Urine (Examination). 
SULPHOCARBOLATE.-The old name for 
phenolsulphonate. A salt of phenolsulphonic acid 
(sulphocarbolic acid). See Phenolsulphonate. 
SULPHONAL.- Sulphonmethane. Acetone 
diethysulphone. It is soluble in 100 parts of 
water at 16° C., in 20 parts at 100° C., and readily 
soluble in alcohol; it crystallizes in colorless leaflets 
or plates that melt at 126° C., and is odorless and 
tasteless. 
Therapeutics.-As a hypnotic sulphonal acts 
admirably in many instances, if administered in 
hot fluids and about 2 hours before its action is 
required; but its efficacy decreases with use, and 
it is of no value whatever against insomnia due to 
pain. The average hypnotic dose is about 20 
grains for a woman and 30 grains for a man. 
The dose is to be administered only once daily, 
and should be discontinued at the first sign of 
toxic action. In no case should its administration 
be continued over any great length of time. In 
cases of insomnia due to neuralgia and nervous 
excitement, the dose of sulphonal may be advan- 
tageously combined with a small dose of morphin, 
in proportion to suit individual cases, the mixture 
forming a safe and efficient hypnotic. An excellent 
hypnotic combination is made by mixing together 
10 or 15 grains each of sulphonal and trional, to 
be taken in some hot liquid at bed-time. The 
trional producing early sleep and the sulphonal 
effects being manifested later, the patient will 
usually obtain a more prolonged result from the 
small dose of each agent administered together 
than from a larger dose of either alone. See 
Trional. 
Poisoning.-The prolonged use of sulphonal may 
give rise to such minor toxic effects as noises in the 
ears, headache, vertigo, weakness, and incapacity 
for mental or physical exertion. The patient may 
next pass into a condition of drowsiness or stupor 
and even death, or he may suffer from difficulty of 
speech; ptosis, edema of the eyelids, and cyanosis 
may occur. The stopping of the drug in subjects 
of sulphonism is followed by vertigo, motor dis- 
turbances, general weakness, digestive disturb- 
ances, etc., a condition resembling that in morphin- 
ism when the morphin is suddenly cut off (Lepine). 
In one reported case a dose of 20 grains nightly 
for 15 months was accompanied by complete 
cessation of menstruation (Potter). It has pro- 
duced persistent skin eruptions in some cases and 
severe functional disturbances in others. The 
chief characteristics of chronic poisoning by this 
drug are as follows: Disturbances of digestion, 
shown by vomiting and diarrhea or constipation; SULPHUR 
SUNBURN 
disturbances of the nervous system, as ataxia and 
feebleness of the limbs, ptosis, and ascending 
paralysis; also ischuria and oliguria, sometimes 
albuminuria, or the presence of hematoporphyrin 
(Karst). Recovery follows rapidly if the entire 
alimentary tract is thoroughly purged; and as 
long as this is kept free, and the kidneys act 
efficiently and normally, the drug may be consider- 
ed harmless (Fuerst). In order to secure elimina- 
tion and to guard against cumulative action and 
consequent toxicity, its administration should be 
interrupted from time to time. Anorexia, vomit- 
ing or pains in the stomach may be regarded as 
indications for immediate discontinuance (Karst). 
SULPHUR (Brimstone).-S = 32; quantivalence 
ii, iv, vi. Sulphur is official in three forms: 
Sulphur Sublimatum, Sublimed Sulphur, pre- 
pared from crude sulphur by sublimation and 
condensation. It is a fine citron-yellow powder, of 
faintly acid taste and acid reaction, insoluble in 
water or alcohol. Ignited it burns with a blue 
flame, forming sulphurous acid gas, and leaving 
no residue or only a trace. Dose, 10 grains to 2 
drams. 
Sulphur Lotum, Washed Sulphur, prepared by 
digesting sublimed sulphur with dilute water of 
ammonia, thoroughly washing with water and 
passing through a sieve. Solubility and dose 
same as for sulphur precipitatum. 
Sulphur Precipitatum, Precipitated Sulphur, Lac 
Sulphuris, Milk of Sulphur, prepared by boiling 
sublimed sulphur with slaked lime and water. It 
is a very fine, yellowish-white, amorphous powder, 
odorless and almost tasteless, insoluble in water or 
alcohol, but completely soluble in carbon disul- 
phid or in a boiling solution of soda. By heat it 
is completely volatilized. Dose, 10 grains to 2 
drams. 
Sulphur is chiefly used as a laxative when 
pultaceous rather than liquid stools are required, 
as in hemorrhoids and anal fissure, also in consti- 
pation. Scabies has long been treated by its 
local and internal use, but sulphur alone does not 
kill the itch insect. The older sulphur ointments 
were made with sublimed sulphur, and probably 
contained a considerable amount of sulphurous 
acid, on which their parasiticide property depend- 
ed. The later ointments, made with purified 
sulphur, all contain an alkaline ingredient and 
develop sulphids, which are powerful insect 
poisons. Sulphur fumigations are practically 
applications of volatile sulphurous acid, while 
most of the sulphur baths and sulphurous mineral 
waters are solutions of sulphuretted hydrogen or 
of the alkaline sulphids. They are of value in 
lead poisoning to favor the elimination of that 
metal, in chronic constipation, chronic rheumatism 
and sciatica and many skin diseases, especially 
chronic psoriasis, eczema, pityriasis and prurigo. 
The ointment is used in scabies. 
Preparations.-S. Dioxid, SO2, a colorless gas of 
irritating odor, formed by the combustion of 
sulphur; and in the presence of moisture acting as 
a powerful bleaching and disinfecting agent. As 
an insecticide it is unexcelled. See Disinfection. 
S. lodidum, I2S2, used as an ointment, 30 grains to 
1 ounce. S. Ung., washed sulphur 15, benzoinated 
lard 85 parts. 
SULPHURIC ACID.-H2SO4. Oil of vitriol, a 
heavy, oily, corrosive acid, consisting of not less 
than 92.5 percent sulphuric anhydrid and 7.5 per- 
cent water. Its uses and actions are the same as 
those of most other mineral acids, particularly 
hydrochloric acid. In lead-poisoning it forms an 
insoluble sulphate. It is used as a remote astring- 
ent in diarrhea, hemorrhoids, hemorrhages, night- 
sweats, and in mucous discharges. It does not 
increase the acidity of the urine. In poisoning by 
sulphuric acid water is to be avoided. Alkalies- 
such as sodium carbonate or bicarbonate, mag- 
nesia, chalk, soap, whiting, and wall plaster-are 
antidotes. Albumin, flour, milk, starch, and oilve 
oil will protect the mucous membranes. Of antag- 
onists, opium, ammonia (intravenously), and al- 
cohol may be given to combat the depression of 
the vital powers. 
Preparations.-Acid, Sulph. Aromatic., contains 
20 percent (by weight) acid, diluted with alcohol 
and flavored with cinnamon and ginger. Dose, 5 
to 15 minims, well diluted. Acid., Sulph. Dilut., 
contains 10 percent strong acid to 90 of water. 
Dose, 5 to 40 minims, well diluted. 
SULPHUROUS ACID.-H2SO3. A colorless 
acid containing about 6 percent sulphurous an- 
hydrid in 94 percent water. The gas, SO2, is a 
very valuble disinfectant. The acid is used as a 
spray or lotion in diphtheria and stomatitis, and as 
a wash for indolent and syphilitic ulcers. The 
various hyposulphites are mainly valuable in that 
they decompose and give off sulphur dioxid. 
Dose, 5 minims to 1 dram. See Magnesium, 
Potassium, and Sodium. 
SUMBUL.-The dried rhizome and root of an 
undetermined plant. It contains angelic and 
valeric acids, also a volatile oil, balsamic resins, 
and a bitter principle. Dose, 10 to 60 grains. 
Sumbul is an efficient nerve tonic, having quali- 
ties closely resembling musk and valerian. It is 
used by the Russian physicians 'in very many 
morbid conditions and seems to be a favorite 
remedy in that country for almost any disease. It 
is probably of some value in hysteria and other 
nervous derangements of delicate females, and 
may be used as a substitute for musk in typhoid 
conditions and fevers, asthma, delirium tremens 
and perhaps in epilepsy. 
Extractum S. Dose, 1 to 10 grains. Fluidex- 
tractum S. Dose, 10 to 60 minims. 
SUMMER COMPLAINT. - See Cholera In- 
fantum, Cholera Morbus. 
SUNBURN.-The superficial local effects of ex- 
posure to the sun's rays. In slight cases little or 
no treatment is required. Pow'dered starch, zinc 
oxid, bismuth or boric acid, or mere sprinkling with 
elder-flower water or rose-water may suffice. A 
solution of ammonium acetate may be pleasant. 
Severe cases require lead lotion, with morphin or 
cocain. Subacetate of lead with glycerin and elder- 
flower water or rose-water makes a good applica- 
tion. Preventive treatment consists in protecting 
exposed parts from the sun's rays. Sunshades, 
veils, and masks are useful but inconvenient. The SUNSTROKE 
SUPPURATION 
greased paints used by actors may be employed 
in sea-bathing. Pigments mixed with glycerin 
of starch are better than those compounded with 
grease. For the freckles following sunburn, lotions 
of mercuric chlorid or boric acid-especially 
when made with almond water in emulsion by the 
use of glycerin-or the juice of cucumber may 
have a beneficial effect. See Freckles. 
SUNSTROKE.-See Heat-stroke. 
SUPERIMPREGNATION.-Two varieties of su- 
perimpregnation are described: (1) Superfecun- 
dation and (2) superfetation. 
Superfecundation is the fecundation of two or 
more ovules at or near the same period of time. It 
occurs in one variety of twin pregnancy. 
Superfetation is the production of conception 
while an embryo already exists in the uterus. Some 
remarkable cases have been reported that would 
seem to prove the possibility of its occurrence. 
That it can occur after a long interval is doubtful, 
however, since there is no proof of ovulation during 
pregnancy. 
SUPERINVOLUTION.-An exaggeration or ab- 
normal prolongation of that process by which 
the uterus regains its normal condition after labor. 
See Involution. 
SUPPOSITORY.-A solid, medicated compound, 
designed to be introduced into the rectum, urethra, 
or vagina. Its consistency is such that, while re- 
taining its shape at ordinary temperatures, it 
readily melts at the temperature of the body. 
The basis of most suppositories is oil of theo- 
broma. For urethral suppositories a mixture 
of gelatin and glycerin is used. It is generally 
molded into a conic shape, but is sometimes 
cylindric or spheric. According to the directions 
in the U. S.P.: Rectal suppositories should be cone- 
shaped or spindle-shaped, and when made from oil 
of theobroma should weigh about 2 grams. 
Urethral Suppositories (Bougies) should be pen- 
cil-shaped, pointed at one extremity, and either 
7 cm. in length, weighing about 2 grams, or 14 cm. 
in length weighing about 4 grams, when made with 
glycerinated gelatin. If prepared with oil of theo- 
broma, they should weigh about one-half the above 
quantities. 
Vaginal Suppositories should be globular or 
oviform in shape and weigh about 10 grams if 
made with glycerinated gelatin, and about 4 
grams if made with oil of theobroma. 
There is one official suppository, the glycerin 
suppository, containing glycerin, monohydrated 
sodium carbonate, stearic acid, and water. 
Anodyne suppository: 
I|. Extract of opium, gr. j 
Extract of belladonna 
leaves, gr. ss 
Extract of hyoscyamus, gr. ij 
Cacao-butter, a sufficient 
quantity to make 6 suppositories. 
Use one in the rectum morning and night. 
SUPPRESSION OF URINE.-See Urine (Sup- 
pression). 
SUPPURATION.-By this term is meant the 
production of pus. While it is true that experi- 
mentally (as by the hypodermic injection of ni- 
trate of silver, calomel, turpentine, abrin and ricin) 
suppuration can be produced without the presence 
of pyogenic bacteria, yet it may be laid down as a 
broad general principal that where there is pus 
there also are found the bacteria or the poisons 
that produce it. 
Pus from an acute abscess in an otherwise healthy 
person is a thick, creamy, opaque, yellowish-white, 
slightly alkaline fluid, with a faint odor, salty taste, 
and a specific gravity of about 1030. If a drop is 
examined under the microscope, it is found to con- 
sist of a fluid (the liquor puris) and corpuscles 
(pus-cells). Some of these corpuscles are globular, 
slightly granular, and measure 1/2400 inch in diam- 
eter, while some contain two or three nuclei, 
which are made more evident on the addition 
of acetic acid to clear up the granular matter. 
Among them may be seen other corpuscles, indis- 
tinguishable from leukocytes, and exhibiting, when 
examined on a warm stage, ameboid movements. 
The latter are living leukocytes and tissue cells; 
the former, leukocytes and proliferated tissue cells 
that have undergone death and degeneration. The 
proportion of dead to living pus-cells varies with 
the duration of the inflammation. The liquor 
puris consists of water, albumin, and salts, of 
which chlorid of sodium is the chief. It coagu- 
lates on boiling. Though probably derived in 
chief part from the exudation of the serum through 
the vessels, it differs from serum in that it does not 
coagulate spontaneously. In acute abscesses the 
pus contains granular material, derived from the 
rapid degeneration of the tissues, and various 
species of microorganisms, usually cocci. If 
allowed to stand or decompose in an imperfectly 
drained abscess cavity, the pus will be found, 
moreover, teeming with the bacteria of putre- 
faction. 
Varieties of Pus.-Normal, healthy (formerly 
called laudable) pus is best illustrated by that 
which is found in staphylococcic infections; it 
tends to remain localized, and the tissues from 
which it comes quickly recover after thorough 
drainage has been established. It is a greenish- 
white, creamy fluid, without odor, alkaline in 
reaction, and of a specific gravity of 1030. San- 
ious pus is mixed with blood, and is sometimes 
seen in caries and carcinoma. Malignant or 
ichorous pus is watery, acid, and very irritating to 
the tissues. Blue pus is due to the bacillus pyocy- 
aneus, orange pus to hematoidin crystals the result 
of degeneration of red blood corpuscles, and 
stinking pus to the bacteria of putrefaction or the 
bacillus coli communis. Concrete or fibrinous pus 
contains flakes of lymph; serous pus, a large quan- 
tity of serum; and muco-pus, mucus.' Gas produc- 
ing pus is due to the bacteria of putrefaction, 
bacillus of malignant edema, bacillus aerogenes 
capsulatus, bacillus coli communis, or to commu- 
nication with one of the air-containing viscera. 
Tuberculous, scrofulous, caseous, or curdy pus, 
found in tuberculous processes, and gummy pus, 
the result of a degenerating gumma, are not, 
strictly speaking, pus. 
The microorganisms that are most active in this SUPPURATION 
SUPPURATION 
process are the staphylococcus, the streptococcus, 
the gonococcus, and the bacillus pyocyaneus. 
The Staphylococcus Pyogenes.-The varieties 
are staphylococcus pyogenes aureus, staphy- 
lococcus pyogenes citreus, and staphylococcus 
pyogenes albus. The staphylococcus pyogenes 
staphylococcus the tendency is to produce a local- 
ized abscess, the streptococcus produces a sup- 
purative process having a tendency to spread 
throughout the tissues. It is supposed to be one 
of the causes of erysipelas. The microorganism 
is not motile, and does not contain spores. It 
grows upon artificial culture media and stains 
with ordinary watery or alcoholic solutions of 
anilin dyes and by Gram's method. 
The streptococcus erysipelatis is described 
under Erysipelas (9. v.). 
The gonococcus was discovered by Neisser, in 
1879, and is the cause of gonorrhea. These small 
hemispheric microorganisms are not motile, like 
other forms of cocci, and have no flagella and no 
spores. For many years attempts to cultivate 
this variety of bacteria upon artificial culture 
media proved futile, but after very painstaking 
effort it has been grown upon a mixture of human 
blood-serum and agar-agar. In the gonorrheal 
pus the microorganism is nearly always found in 
pairs within the epithelial cells. It stains best 
with rather weak, watery solutions of anilin dyes, 
but not by Gram's method. See Gonorrhea. 
The bacillus pyocyaneus is a short, delicate 
bacillus of small size, frequently united in chains 
of 4 or 6. It has round ends, is actively motile 
Staphylococcus Pyogenes Aureus, Pure Culture. 
X 1000.-(Williams.) 
aureus is the one most commonly found in all 
cases of localized suppuration. The arrangement 
of the growth is in the shape of a bunch of grapes; 
hence the name "staphylococcus." These varie- 
ties of the staphylococcus grow upon artificial 
culture media, and from their chromogenic 
properties in this respect produce various colors: 
"aureus," orange or golden color; "citreus," 
lemon color; "albus," white color. The different 
forms are not motile and are without spores. 
They stain with the ordinary watery or alcoholic 
solutions of anilin dyes and by Gram's method. 
Bacillus Pyocyaneus.-(Kolle and Wassermann.) 
has one terminal flagellum, does not form spores, 
and is almost purely aerobic. It stains well with 
ordinary solutions, but does not retain the color 
by Gram's method. It is found in pus of a pecu- 
liar bluish or greenish color. 
Method of Staining for Staphylococci, Strepto- 
cocci, and Gonococci.-Upon a perfectly clean 
cover-glass place a drop of the pus to be examined, 
and upon this place a similar cover-glass. Sepa- 
rate them horizontally, and dry in the air. With 
a pair of forceps grasp one edge of the cover-glass 
and pass through the flame of an alcohol lamp or 
Bunsen burner 3 times, each time allowing the 
specimen to occupy about 3 seconds in its passage 
through the flame. Upon this specimen then pour, 
by means of a pipet, a saturated aqueors or alco- 
holic solution in the case of streptococcus or staphy- 
lococcus pyogenes, but a weak, watery solution in 
case of gonococci of one of the anilin dyes, prefera- 
bly methylene-blue, and allow it to remain for 
Streptococcus Pyogenes, from a Pure Culture. 
X 1000.-(Williams.') 
Streptococcus Pyogenes.-In this variety of 
pyogenic cocci the arrangement of the organism 
in its growth is in the shape of chains; hence the 
name "streptococcus." While in the case of the SUPPURATION 
SUPPURATION 
from 1/2 to 2 minutes; then rinse in water and 
mount in Canada balsam. 
Gram's Method of Staining Bacteria.-Fix the 
specimen on a cover-glass. Instead of using 
the ordinary anilin dyes in alcoholic or watery 
solution, the following is used. It should always 
be freshly prepared (Ehrlich's solution): 
Pure anilin, 4 gm. 
Saturated alcoholic solution of 
gentian-violet, 11 gm. 
Water, 100 c.c. 
Grasp the prepared specimen with a pair of for- 
ceps, and pour upon it a few drops of the above 
solution and warm over the flame for from 2 to 5 
minutes, constantly adding the solution. Remove 
and place in: 
lodin crystals, 1 gm. 
Potassium iodid, 2 gm. 
Water, 300 c.c. 
Allow the specimen to remain in this solution 
for from 2 to 5 minutes, wash in 95 percent alcohol, 
and counter-stain with eosin or Bismarck brown. 
Circumscribed Suppuration or Abscess.-An 
abscess is "a circumscribed cavity of new forma- 
tion containing pus." According to location, 
abscesses are named dorsal, iliac, mammary, 
ischiorectal, perityphlitic, retropharyngeal, urethral, 
etc. Abscesses are also known as superficial, 
deep-seated, acute or phlegmonous, chronic, com- 
mon, specific, and residual. 
An acute abscess is one that runs its course 
rapidly, and is always accompanied by well- 
marked inflammatory symptoms. It is, from its 
great frequency, one of the most important of 
surgical diseases. When an inflamed part becomes 
more heated and more swollen; when the skin 
assumes a dusky hue, and becomes glossy and 
shiny; when the pain, which has been of a dull, 
heavy nature, becomes persistent, steady, and 
throbbing, and when the skin over the swelling 
is edematous, then there can be no doubt that 
an abscess has formed. 
Pathology.-In the formation of an abscess the 
first phenomena are those of inflammation, which 
have been described; when the production of 
embryonic tissue has been reached, if it stops at 
that point, resolution is established and recovery 
ensues; but should the new "cellular infiltrate" 
be invaded by any microorganism of suppuration, 
and a suitable soil for its nidus and growth be 
found, their excreta, known as ptomains, peptonize 
the fibrin and change the embryonic tissue to a 
liquid, which is pus. The changes here described 
begin in the lymph spaces, so that an abscess never 
has its commencement at a single focus; the accu- 
mulation of liquid and of cells causes the lymph 
spaces to be greatly distended; the fibrous tissues 
separating these spaces are widely pressed asunder, 
causing their supply of blood to be cut off, slough- 
ing being the result; moreover, the living pus-cells 
find in these fibers a source of nourishment, and 
they are thus destroyed; hence the lymph spaces 
become converted into a single cavity, and an 
abscess is formed. 
From the periphery to the center of an abscess 
all stages of inflammation are presented, from the 
first, which is the stage of congestion, to the last, 
which is the period of the formation of pus. Be- 
tween these two conditions there is a middle point, 
when the inflammatory process has reached only 
the formation of embryonic tissue; and hence it is 
that the cavity of an abscess is always circum- 
scribed by a tissue of new formation. Not only 
does an abscess extend in various directions, but 
all abscesses tend to empty themselves at the point 
of least resistance; they approach the surface, 
where they spontaneously evacuate themselves, 
their tendency being toward the skin. The 
abscess discharges itself by a small opening, which 
is due to the death of a limited portion of the skin. 
The contents of an acute or phlegmonous abscess 
are pus, micrococci, and some shreds of dead 
tissue. In some cases the abscesses contain air, 
when the contents are extremely fetid. 
Diagrammatic Representation of the Minute Changes 
in the Formation and Healing of an Abscess. 
The upper half shows abscess enlarging; the lower half 
abscess healing.-{Walsham.) 
Phlegmonous abscess occurs in all periods of 
life and in all classes of persons; it varies in size, 
and is frequently found in subcutaneous connec- 
tive tissue, in the muscular tissue, around the 
lymphatic glands, and around the bones. Its 
most common sites in the viscera are the liver and 
the brain. 
Chronic Abscess.-The effect of the bacillus of 
tuberculosis on tissue is to produce a chronic 
inflammation, which results in the production of 
granulation tissue; this is the so-called pyogenic 
membrane of old authors, and acts as a protective 
wall to the surrounding tissue. The degenerative 
changes that take place are caused by local 
anemia and by the chemic action of the ptomains 
of the tubercle bacilli; they consist of caseation 
and liquefaction of the cheesy material. This 
purulent material has hitherto been looked upon 
as pus; it is now known to be tissue that has 
undergone metamorphosis. Pus is never present 
in a tubercular process unless the microorganism 
of suppuration is present, when there will be a 
mixed or double infection. SUPPURATION 
SUPRARENAL DISEASE 
If the bacillus meets with a double resistance 
from the surrounding tissue, it exhausts the 
nutritive material in the granulations and dies; or 
it remains in a latent condition; the granulation is 
converted into a cicatricial tissue, and the local 
lesion is cured. This is designated spontaneous 
cure. The liquid may also be absorbed, when a 
similar favorable termination is possible. If the 
cavity is opened under antiseptic precautions, cure 
is accelerated; if, however, secondary infection 
with pus microbes takes place, the patient is in 
danger of septic infection as well as of local and 
general dissemination of the tubercular process. 
Treatment of Abscess.-The chief indications are 
to remove the pus with as little injury to the 
tissues as possible, to insure sufficient drainage, 
and to maintain the parts in an aseptic condition. 
When it is evident that suppuration must ensue, it 
should be promoted by moist warmth in the form 
of a large boric acid poultice sprinkled with opium 
or hot poppy fomentations. As soon as fluctua- 
tion is detected, the abscesses should be opened by 
making a free incision in the most dependent part 
or where it is pointing, of course taking care to 
avoid blood-vessels or other important structures 
in the neighborhood. The pus should generally be 
allowed to flow out of its own accord. To insure 
thorough drainage, and to prevent any tension 
from reaccumulation, the opening should be free 
and a drainage-tube should be inserted. If the 
abscess is large, a counteropening may be neces- 
sary, or the abscess cavity may degenerate into a 
sinus. If the drainage is efficient, no harm will 
ensue if a poultice-the favorite treatment of the 
older surgeons-is applied; but if the abscess is 
deep and the aperture small, and there is thus 
danger of the pus being retained and undergoing 
decomposition, antiseptic dressings or boric acid 
fomentations should be used, as under these cir- 
cumstances the retained discharge will probably 
be under some degree of tension, and the granula- 
tion walls of the abscess hence inefficient to prevent 
absorption. Although it is a rule in surgery to 
open an abscess as soon as fluctuation clearly 
shows that pus has formed, there are some in- 
stances in which this is especially imperative. 
Thus, an abscess should be opened at once when 
it is situated in the perineum, in the abdominal or 
thoracic walls, in the sheath of a tendon, under 
a deep fascia or the peritoneum, in the orbit, near 
a joint, and in the neck if attended by dyspnea; 
when obstructing some passage; when caused by 
the infiltration of urine, feces, etc., and when a 
spontaneous opening would produce deformity. 
Hilton's method, as it is called, of opening an 
abscess is very useful when the abscess is situated 
deeply and among important structures, as at the 
root of the neck or in the axilla. It consists of 
making an incision through the skin and fascia and 
then working gently in the direction of the pus 
with a director. As soon as pus presents, a pair of 
dressing forceps are slid along the groove of the 
director into the abscess cavity, the director is 
removed, and the blades of the forceps are sepa- 
rated so as to stretch the opening and make a free 
exit for the pus. 
The complications of acute abscess are: (1) 
Hemorrhage from the involvement of a large 
vessel; (2) the implication of some important part, 
as the peritoneal cavity, the interior of a joint, etc.; 
(3) degeneration into a sinus or fistula; (4) blood- 
poisoning (sapremia, pyemia). 
The chronic abscess must not be allowed to open 
itself spontaneously. This precaution is to be 
particularly borne in mind when the glands of the 
neck are affected. Open the abscess in the most 
dependent portions, using a straight, sharp bis- 
toury for the purpose; press out the accumulated 
material; scrape out the abscess thoroughly; wash 
it with an antiseptic solution of bichlorid of mer- 
cury, then bring the opening together by means of 
a suture; insert a drainage-tube and place iodoform 
gauze upon the outside. Before opening an 
abscess of large size, and after ether has been 
administered, give 1/6 grain of morphin, hypo- 
dermically, and also administer 1/6 grain of 
opium every 8 hours. The effect of opium is to 
prevent capillary hemorrhage after the removal of 
pressure. 
Constitutional Treatment.-When the suppura- 
tion is profuse, tonics-such as iron, quinin, and 
strychnin-together with good, nutritious diet, 
milk-punch, etc., and change of air, must be 
insisted upon. 
To repair waste from suppuration: 
I|. Syrup of iron, quinin, and 
strychnin, 3 vj. 
A teaspoonful in water thrice daily. 
I). Syrup of hypophosphites, 3 vj. 
A dessertspoonful thrice daily. 
The injection of bacterial vaccines although 
at one time recommended, has not proved of so 
much value in the treatment of abscess as it has 
in superficial infections such as furuncles. In fact 
it is probably worthless, and at most is uncertain 
and unsatisfactory. If employed at all it should 
be used only as a supplement to surgical and 
general medicinal measures. See Vaccine 
Therapy. 
See Brain (Inflammation), Hectic Fever, 
Liver (Abscess), Psoas Abscess, Spine (Caries), 
Sepsis etc. 
Diffuse suppuration may occur either in the 
substance of tissues or organs, or on the surface of 
the skin or of the mucous or serous membranes. 
An example of the former is cellular erysipelas. 
Examples of the latter are seen in gonorrhea, 
bronchitis, and peritonitis. These affections are 
all discussed under their separate headings. 
SUPRARENAL DISEASE (Addison's Disease; 
Adrenal Disease).-A well-marked, constitutional 
disease, exhibiting itself locally as a chronic 
inflammation of the suprarenal capsules, but in its 
essence consisting of a peculiar anemic condition, 
always tending toward death; and which is charac- 
terized by intense development of pigment in the 
cells of the rete malpighii and in the epithelium 
of the mucous membrance of the mouth. 
The etiology is obscure. Tubercle, scrofula, 
and syphilis have each been given as the cause. SUPRARENAL EXTRACT 
SUPRARENAL EXTRACT 
Pathologic Anatomy.-A low form of inflam- 
mation, terminating in degeneration of the su- 
prarenal capsule. The blood is deficient in fibrin 
and red corpuscles, with a slight increase of the white 
corpuscles. Fatty degeneration of the heart and 
vessels has been observed in some cases. The 
most striking change during life-the abnormal 
pigmentation-is due to the deposition of granular 
pigment in the cells of the rete malpighii, in the 
papillary portion of the cutis, and even in the con- 
nective-tissue corpuscles. No change occurs in 
the proper structure of the skin. Similar pigment 
deposits occur in the mucous membrane of the 
mouth, especially along the edges of the teeth. 
The disease of the suprarenal capsules excites an 
irritation of the vasomotor system-the trophic 
system-that leads to the pigmentation. 
Symptoms.-The onset of the disease is insidious, 
with a feeling of extreme languor, muscular 
fatigue, asthenia, indigestion, anorexia, dyspnea, 
cardiac palpitation, vertigo, melancholia, and 
excessive drowsiness. The surface is first pale, 
then changes to a hue like that seen in melancholia, 
changing to icteroid, finally resembling the color 
of a mulatto, and then to a lusterless bronze. 
These changes also occur on the mucous membrane 
of the lips, tongue, gums, and mouth. 
Prognosis.-The disease is incurable. The dura- 
tion is 1 or 2 years. 
Treatment is symptomatic, and is of little use. 
Arsenic and cod-liver oil give the best results. 
Iron and other tonics are useful, especially a com- 
bination of the chlorid of iron, glycerin, and chloro- 
form. Phosphorus has seemed to exert a benefi- 
cial influence. Adrenal extract has been employed 
in a few cases, with some benefit while used. 
mucous surfaces, no absorption taking place 
sufficient to produce any evidence of constitutional 
effects. The pupil, accommodation, and intra- 
ocular tension are in no way affected. It has ab- 
solutely no action on the skin, nor does it possess 
any anesthetic properties wherever applied. Its 
action is wholly but strongly astringent; hence its 
efficacy in preventing hemorrhage during an 
operative procedure on mucous membranes. The 
depletion is complete. Maurange first recom- 
mended it for the prevention of hemorrhage in 
eye operations. Its local effects are enhanced 
by a preceding application of cocain or anti pyrin 
solution. When applied locally for either thera- 
peutic or operative purposes, it should always 
be preceded by a 5 percent solution of cocain, so 
as to secure the combined anesthetic and enhanced 
effects of the cocain and extract. The adrenal 
capsule has of itself no anesthetic properties, be- 
ing purely astringent, and then only when applied 
to the mucous surfaces. The astringent action 
begins in from 30 to 40 seconds, and lasts from 
1/2 of an hour to 3 hours, after which interval 
the mucous membrane returns to its normal 
condition. The solution of the capsule is not at 
all irritating, but rather imparts a cooling sensation 
to the conjunctiva. 
A preparation made by placing 5 grains of desic- 
cated suprarenals in 1 dram of cold, saturated 
boric acid solution and allowing the mixture to 
stand 10 minutes before filtering, applied locally, 
relieves congested mucous membrane, and pre- 
vents hemorrhage, thus enhancing and prolonging 
cocain anesthesia. Its full effect is noticed in a 
few seconds, and lasts from 1 to 2 hours. The 
extract is not antiseptic nor anesthetic, and no 
tolerance is established by its use. Fresh solutions 
should be prepared for each operation. Powdered 
desiccated suprarenal capsules of the sheep, 
1 grain representing 8 grains of the fresh sub- 
stance, in ounce bottles, are for sale. 
Internally, suprarenal extract has been given 
with great benefit in shock and hay-fever. It has 
been used in Addison's disease, pernicious anemia, 
diabetes insipidus, diabetes mellitus, cyclic albu- 
minuria, and heart disease, in doses of from 3 to 
5 grains, 2 or 3 times daily. This extract has 
given good results in nasal, pulmonary and 
gastric hemorrhage, acute and chronic bronchitis, 
bronchial asthma, congestion and edema of the 
lungs, edema of the glottis and diabetes insipidus. 
It will be found useful in chronic muscular affec- 
tions, especially those involving loss of tone or 
degenerative changes, and will probably be found 
valuable in all conditions in which the vaso- 
motor tone is impaired. Being a powerful but 
temporary stimulant of the heart it may be used 
cautiously in cardiac weakness, in failure of the 
heart from any cause and in valvular diseases 
of that organ. 
By local application the angiostenotic properties 
of suprenal extract have been successfully utilized 
in the treatment of local congestions, inflamma- 
tions and hemorrhages, especially those of the eye, 
ear, nose and throat. It is an excellent hemo- 
static for hemorrhage following operations on the 
1$. Tincture of iron 
chlorid, 
Spirit of chloro- 
form, 
each, 3 j 
Glycerin, 5 vj. 
A dessertspoonful in water thrice daily. 
SUPRARENAL EXTRACT (Adrenal Extract).- 
The selected dried and powdered suprarenal 
capsules of oxen and sheep. One part of this 
powder represents 5 parts of the fresh organ. 
Systemically, its effects are principally on the cir- 
culatory and nervous systems. It is a remarkable 
astringent, and is much used in operations upon the 
eye, ear, nose, and throat and in the treatment of 
local congestions, inflammations and hemorrhages, 
especially of the eye, ear, nose and throat. When 
applied to any mucous surface, it produces more 
or less profound ischemia, depending on the strength 
of the solution and the manner and time of applica- 
tion. Locally applied, it is never followed by any 
constititutional manifestations. The bloodless 
condition of the mucosa is unmistakably due to the 
local action of the extract on the vasoconstrictors 
of the capillaries, constricting them and inducing 
bleaching of the surface. No injurious effects to 
the tissue follow the continuous application, nor 
is there any danger of contracting a habit, as the 
action of the adrenal extract is purely local on SUSPENDED ANIMATION 
SWEAT-GLANDS, DISEASES 
nose, and is used as an application to inflamed 
tissues prior to their being anesthetized by cocain, 
also to the mucous membrane of the turbinated 
bodies in ulceration or hypertrophy thereof. 
Suprarenaden is a preparation made from the 
suprarenal capsules, used in Addison's disease, 
menopause, neurasthenia, and diabetes insipidus. 
Dose, 15 to 23 grains daily. See Adrenalin. 
SUSPENDED ANIMATION.-See Asphyxia; 
Syncope. 
SUSPENSION.-A mode of treatment of certain 
diseases, especially tabes dorsalis, in which the 
patient is so placed that the whole weight of the 
body hangs upon the neck, the head being sup- 
ported at the chin and the occiput. The stretch- 
ing of the spinal cord sometimes removes the 
morbid process in a manner at present not well 
understood. See Spine (Diseases). 
SUTURE.-A stitch used in closing the edges of 
a wound. Suture material may be of silk, silk- 
worm-gut, catgut, or other animal material, and 
of metal. See Ligature. 
The Interrupted Suture.-The needle, carrying 
a single ligature, is passed through the skin on one 
side of the wound from without inward, and is 
then inserted from within outward at the corres- 
ponding point on the opposite side of the wound. 
The ends of the ligature are drawn together and 
tied tightly in a double knot. The ligature is 
then cut and another suture introduced at an 
interval of 1/2 of an inch, and so on. 
Lembert's interrupted suture is recommended in 
wounds of the intestines. The stitches should be 
3/8 of an inch from the margin of the wound, the 
middle suture being first introduced; the distance 
between the sutures should not exceed 1/4 inch. 
When the requisite sutures have been applied, the 
ends are to be tied, and cut off close to the knot. 
The bowel is then returned to the abdominal 
cavity and a glass drainage-tube inserted. 
The Twisted or Harelip Suture.-Having placed 
the edges of the wound accurately in contact, a 
sufficient number of needles are passed through 
the edges of the wound. When the necessary 
number of needles have been introduced and the 
parts have been accurately adjusted, the middle of 
the long ligature is twisted around the uppermost 
needle in the form of a figure oo . Then the two 
ends of the ligature are brought down and twisted 
around the other needles successively, when they 
are secured by a knot. After insertion the points 
of the needles must be cut off with pliers. The 
upper pin must be removed at the end of the 
second day, and the lower pin at the end of the 
third day. 
The Glover's or Continuous Suture.-This suture 
is employed in wounds of the intestines and abdo- 
men. It is applicable to cases of injury of great 
extent when there is tendency to the escape of 
fecal matter in the intervals between stitches. It 
is merely the ordinary stitch employed for sewing 
materials together; it is made by simply passing 
the needles diagonally from one side of the wound 
to the other. 
The figures on the next two pages illustrate the 
principal sutures. 
SWALLOWING, DIFFICULT.-See Dysphagia. 
SWEAT-GLANDS, DISEASES. 
Hyperhidrosis (Excessive Sweating). 
A functional disorder of the sweat-glands 
characterized by an excessive secretion of sweat. 
The affection may be general or local. 
Symptoms.-The hands, when affected, are cold 
and clammy. In severe cases the sweat drops 
from the palms, incapacitating the patient from all 
manual work. The feet, when affected, become 
tender, so that walking produces pain. The soles 
are reddened and the epidermis is macerated. 
Etiology.-General hyperhidrosis results from 
faulty innervation. It may, however, be physio- 
logic, as during violent muscular exertion. The 
local forms are probably due to some disturbance 
of the vasomotor apparatus. 
Treatment.-In general hyperhidrosis constitu- 
tional remedies are to be employed-belladonna 
or atropin, ergot, nux vomica, mineral acids, 
quinin, etc. Crocker speaks highly of sulphur, 
given in 1-dram doses twice daily, for both general 
and local sweating. For the local forms the 
remedies are, for the greater part, to be applied to 
the affected regions. Upon the palms this condi- 
tion is much more refractory to treatment than 
upon the soles. The following prescription will 
be found of great value in the treatment of sweat- 
ing feet: 
1$. Salicylic acid, gr. xx 
Boric acid, 5 j 
Lanolin, 
Petrolatum, 
each, 5 ss. 
The feet should not be washed more than once 
a week. It is well also to place boric acid in the 
stockings. Hebra's plan was to wrap up the feet 
in diachylon ointment, and continue the treatment 
for a fortnight. Crocker recommends the use of 
belladonna ointment. All of these remedies will 
be found more efficient in sweating feet than in 
sweating hands. To check sweating of the axillae 
apply, for a few hours, a sponge soaked in very hot 
water. Faradization and galvanization are some- 
times of value in hyperhidrosis. 
To be rubbed in well at bedtime. 
Bromidrosis (Osmidrosis). 
A functional disorder of the sweat-glands, 
characterized by sweat secretion of an offensive 
odor. The condition may be symptomatic, as in 
uremia, rheumatism, etc. There is usually an 
excessive sweating, although the amount may be 
normal. The odor is often so unpleasant as to 
unfit the sufferer for society. The etiology is 
obscure. It usually occurs upon the feet of young 
persons. The sweat is not offensive when se- 
creted, but soon becomes so from the action of 
microorganisms. The treatment is practically 
that of hyperhidrosis. 
Anhidrosis. 
A disorder of the sweat-glands characterized by 
diminution or suppression of sweat. 
It may be symptomatic, as in diabetes, fevers, 
etc. It may also be due to faulty innervation. SUTURE 
SUTURE 
Continuous Suture. 
Hou/ to do it. 
^Hownot to doll 
Harelip Suture. 
Interrupted Suture. 
Quilled Suture 
Jobert's Suture. 
Quilled Suture. 
Tongue and Groove Suture. 
Quilted Sutures. 
Button Suture. 
Lembert's Suture. 
Sutube of Le Dentu. 
Tendon Suture of Le Fort. 
Tendon Suture.-(Wolfler, after Lefars.) SUTURE 
SUTURE 
Gely's Suture. 
Halsted's Plain Quilt Suture. 
Dupuytren's Suture. 
Emmet's Method. 
Bouisson's Suture. 
Jobert's Invagination Suture. 
Sutures for Immediate Gastrostomy. 
Sutures for Immediate Gastrostomy. SWEAT-GLANDS DISEASES 
SYCOSIS 
There may be but slight diminution of sweat 
secretion or total absence. In congenital cases no 
treatment is of avail. In acquired cases one may 
employ massage, electricity, vapor and alkaline 
baths, etc. 
heat. Constipation should be avoided. Sedative 
lotions and dusting-powders constitute the local 
treatment. The following is a useful combination: 
I}. Phenol, n; xxx 
Boric acid, 5 j 
Zinc oxid, 3 jss 
Glycerin, 3 ij 
Alcohol, 5 ij 
Water, add enough to make, o vj. 
Sop on the skin as indicated. 
Or a dusting-powder may be used: 
A disorder of the sweat-glands characterized by 
colored sweat. There are two forms-idiopathic 
and accidental (color due to certain substances 
taken into the system). The color in the idio- 
pathic form is usually black or sepia. The orbital 
region is usually affected. 
Accidental Forms.-Green sweat is found fre- 
quently in copper workers. Red sweat, which 
occurs often in the axilte, is due to the action of 
the bacterium prodigiosum, and is often associated 
with leptothrix. 
The treatment is based upon broad general 
principles. 
Chromidrosis. 
1$. Magnesium carbon- 
ate, 
Boric acid, 
Powdered starch, 
each, 3 ij. 
An excellent method is to sop on a saturated 
solution of boric acid, and follow this with a 
dusting-powder. When the entire body is in- 
volved, bran, starch, or alkaline baths may be 
employed with good results. 
SWEATING SICKNESS.-See Miliary Fever. 
SWEET OIL.-See Olive Oil. 
SWING.-An apparatus consisting of a cradle 
that moves on wheels along a horizontal bar on an 
iron framework; it is used in the treatment of 
fractures of the lower extremities. 
Uridrosis. 
A condition characterized by the excretion 
through the sweat-glands of constituents of the 
urine in considerable quantity. The sweat nor- 
mally contains small quantities of urea. In 
suppression of the urine, as in Bright's disease, 
cholera, etc., urinary products are eliminated 
through the sweat-glands. There is a urinous 
odor to the skin, and sometimes a deposition of 
salts on the skin. 
Hematidrosis (Bloody Sweat). 
A condition characterized by hemorrhage 
from the sweat-pores. 
The affection is very rare. It occurs in young 
hysteric women. It has been observed on the 
face, ears, umbilicus, hands and feet. 
An eruption characterized by the formation 
of numerous superficial, pinhead-sized, trans- 
parent vesicles, occurring during the course 
of febrile diseases. The vesicles are non-in- 
flammatory. They have been aptly described 
as resembling "dewdrops." They are most 
abundant upon the trunk and neck, and dis- 
appear in the course of a few days. The vesicles 
are due to a collection of sweat in the upper layers 
of the epidermis, as a result of obstruction of the 
sweat-ducts. The affection undergoes spontaneous 
involution. 
Sudamen (Miliaria Crystallina). 
Salter's Swing. 
SWOONING.-See Syncope. 
SYCOSIS.-Chronic inflammatory disease of the 
hair follicles, usually of the bearded region, charac- 
terized by papules, pustules, and tubercles per- 
forated by hairs. 
Symptoms.-The disease commences by the 
formation of discrete pinhead-sized to pea-sized 
papules or pustules at the sites of hair follicles. 
The pustules are flat or acuminated, and contain a 
yellowish fluid; they show no disposition to rup- 
ture, but dry into crusts. The surrounding skin 
is reddened, sometimes swollen and infiltrated, and 
is the seat of a variable amount of itching, burning, 
and pain. The pustules are discrete, but may be 
closely aggregated. A hair perforates the center 
of each lesion. In the beginning the hair is firmly 
attached; but as suppuration becomes free, it is 
more easily extracted. At times tubercles are 
present. The eruption comes out in crops, the 
disease lasting for months, or even for years. The 
A mild inflammatory affection, caused by 
obstruction of the sweat-ducts, characterized by 
the occurrence of small papules and vesicles at 
their mouths. 
Symptoms.-The affection comes on suddenly, 
after profuse perspiration. The lesions are dis- 
crete, never tending to coalesce. Itching is 
usually present. The trunk is the seat of pre- 
dilection. In children it is likely to be com- 
plicated by furunculosis. 
Pathology.-Obstruction of sweat-ducts, with 
surrounding inflammation. 
Treatment.-Prophylactic. Children should be 
lightly clad in thin woolens and kept out of the 
Miliaria (Prickly Heat). SYCOSIS 
SYMPATHETIC OPHTHALMIA 
affection is confined to hairy regions, particularly 
the beard and mustache. 
Etiology.-The disease obviously occurs only in 
adult males. It is due to invasion of the follicles 
by microorganisms, chiefly the staphylococci 
aureus, citreus, and albus. Nasal discharge may 
produce a sycosis of the upper lip. 
Pathology.-The pathologic process consists of a 
folliculitis and perifolliculitis, due to pyogenic 
cocci. The inflammation is at first perifollicular, 
the follicle only becoming secondarily invaded by 
serum and pus. 
Diagnosis.-Sycosis vulgaris may be confounded 
with tinea sycosis and pustular eczema. The 
differential diagnosis is appended: 
1$. Precipitated sulphur, gr. xxx to 5 j 
Petrolatum, 3 j. 
A mercurial ointment often acts efficiently: 
I). Ammoniated mercury,gr. xv to xxx 
Petrolatum, 3 j. 
The following formula is highly spoken of: 
1$. Ichthyol, 3 j to ij 
Petrolatum, 3 j. 
A lotion of bichlorid of mercury, 1/4 to 1 grain 
to the ounce, sopped on frequently, is often fol- 
lowed by good results. 
Ichthyol is of value especially when introduced 
by cataphoresis, a 10 percent solution at the cath- 
ode. Pyoktanin introduced in the same way is 
also advocated. Sodium sulphite in solution with 
glycerin and water applied locally is recommended. 
Copper sulphate as a lotion combined with zinc 
sulphate is highly praised. The X-rays have 
proved efficacious. 
SYMPATHETIC OPHTHALMIA.-An inflam- 
mation of the ciliary body, iris, or choroid, or a 
combined inflammation of any or all of these in 
one eye, due to injury in the other eye. 
Cause.-The usual cause is an injury to the cili- 
ary body, or incarceration of the ciliary body and 
iris in a scleral wound. A foreign body in one eye, 
causing cyclitis, is often followed by sympathetic 
inflammation in its fellow. The manner in which 
sympathetic inflammation is produced is not 
clearly understood. Mackenzie supposed that 
sympathetic inflammation passed from the retina 
of the injured eye through the chiasm, to the retina 
of the other eye. Deutschmann suggested that 
germs travel along the optic sheath through the 
chiasm into the sheath of the opposite nerve, and 
thence into the eye. Bacteriologic infection of 
the sympathetically affected eye can rarely be 
proved. A more recent theory is that the path of 
irritation is from the first eye through the ciliary 
nerve to the ciliary ganglion; through the sym- 
pathetic root of the latter to the carotid plexus of 
the same side; then through the circle of Willis to 
the carotid plexus of the other side; and then in a 
centrifugal direction to the ciliary ganglion and the 
ciliary nerves of the second side. The time of out- 
break of the secondary attack varies from 4 to 8 
weeks after the original lesion, but cases have been 
reported from 2 weeks to 40 years afterward. 
Symptoms and Diagnosis.-The premonitory 
symptoms are those of sympathetic irritation- 
asthenopia, photophobia, lacrimation, reduced 
accommodation, cloudy vision, and a mild peri- 
corneal injection. The aqueous may be mode- 
rately opaque and the disc slightly reddened. As 
the stage of true sympathetic inflammation ensues, 
signs of inflammation corresponding to exacerba- 
tions of inflammation in the exciting eye are 
noticed. The ciliary region becomes extremely 
tender; cyclitis, iritis, or some form of keratitis 
becomes visible. The pain and cloudiness in- 
crease, and the visual acuity steadily diminishes. 
Synechiae may form, and the intraocular tension 
becomes at first increased, and afterward dimin- 
ished, as atrophy begins. It is the rule, after 
Sycosis. 
1. A typical case shows 
small discrete pap- 
ules or pustules 
pierced by hairs. 
2. Hairs firmly attach- 
ed until free sup- 
puration occurs. 
Roots often swollen 
with pus. 
3. Course slow. Little 
change from week 
to week. 
4. Mustache frequently 
affected. 
5. Absence of fungus in 
hairs. 
Sycosis. 
1. Lesions strictly fol- 
licular, pierced by 
hairs. 
2. Eruption limited to 
bearded region. 
3. Absence of oozing. 
4. Itching slight. 
Tinea Sycosis. 
1. A typical case shows 
large, lumpy, or 
nodular tumefac- 
tions. 
2. Hairs broken and 
easily extracted. 
Roots usually dry. 
3. Course rapid. Mark- 
ed changes from 
week to week. 
4. Mustache practic- 
ally never affected. 
5. Trichophyton fungus 
in hairs. 
Eczema Pustulosum. 
1. Lesions likely to be 
interfollicular as 
well. 
2. Tends to spread upon 
nonhairy regions. 
3. Oozing marked. • 
4. Itching more severe. 
Prognosis.-Very few cases are incurable. The 
disease, however, is often refractory to treatment, 
and lasts months or years. Recurrences are 
common. 
Treatment.-Internal remedies, such as iron, 
arsenic, cod-liver oil, etc., are at times indicated by 
the general condition of the patient. 
External treatment, however, is far more im- 
portant. An essential step in the local treatment 
is the systematic shaving or clipping of the hairs. 
The beard should be closely clipped with scissors, 
or, better still, shaved every 2 or 3 days. When 
suppuration is free, daily depilation should be 
practised. 
When the inflammatory signs are marked, 
soothing lotions-such as lotio nigra or saturated 
solution of boric acid, or ointment of cold cream, 
oxid of zinc ointment, etc.-may be employed. 
Most cases, however, require more stimulating 
applications. 
As in most follicular inflammations, sulphur is 
of great value here. It is best employed in salve 
form, although lotions may also be used: SYMPHYSEOTOMY 
SYNCOPE 
varying improvement and relapse, to find an adher- 
ent iris, cataractous lens, or atrophied globe from 
deficiency in vitreous, causing retinal prolapses 
and incurable blindness, despite all treatment. 
However, it is possible to retain some indistinct 
vision in favorable cases; but the process is always 
prone to relapse, and the inevitable result follows. 
Treatment is preventive, and must interrupt the 
nervous connection between the eye first involved 
and the one showing signs of sympathetic inflam- 
mation. It has been suggested that this be accom- 
plished by cutting the ciliary nerves. Several 
different methods have been proposed, one of 
which is to cut completely through the optic nerve, 
expose the posterior pole of the eyeball, and cut 
the ciliary nerves entering at this location. Evis- 
ceration has also been proposed. The only cer- 
tain method of prevention and cure is enucleation 
of the eye first affected. This is so important a 
subject that the concise rules laid down by Fick 
are given here as a guide: 
1. If the first eye is blind, painful, and sensitive 
to pressure, enucleation is to be advised; it is to be 
urged if the patient lives a distance from a surgeon, 
and thus may be in danger of overlooking the 
beginning of sympathetic inflammation. If the 
patient will not consent to the operation, he 
should be told to seek aid at the first sign of visual 
disturbance or of inflammation in the other eye. 
2. If the first eye has a foreign body in it, and is 
painful and sensitive to pressure, enucleation 
should be urged, even if the eye sees; it is to be 
supposed, of course, that the foreign body cannot 
be removed independently. 
3. If the sympathetic inflammation, or even 
irritation, appears in the second eye, the first must 
be enucleated at once. If the first eye is not blind, 
but still retains a certain visual acuity, and is to 
some extent quiet, both patient and surgeon will 
hesitate at such radical proceedings. There is, 
however, no general rule for such a case. The 
visual acuity of the first eye must be carefully com- 
pared with the degree of irritation in the second; 
the more there remains to rescue in the second eye, 
the greater price can be paid by the first. 
If the sympathetic inflammation is fully devel- 
oped, enucleation proves of litte value, and the 
pain must be lessened by cocain, atropin, warm 
compresses, and bandages, and the patient must be 
confined to bed. Mercurial inunctions and sub- 
conjunctival sublimate injections have been 
advised; iodids and mercurials may be given orally; 
but despite all treatment, the eye is generally lost. 
SYMPHYSEOTOMY.-The subcutaneous sepa- 
ration of the symphysis pubis for the purpose of 
enlarging the pelvic diameters. The maximum 
degree of separation of the pubic bones is 7 cm. if 
injury to the sacroiliac joints is to be avoided. 
By this amount of separation there is gained in 
the true conjugate diameter 1.5 cm.; in the oblique 
diameter, 3.5 cm.; and in the transverse diameter, 
3 cm. By this means safe delivery is secured, 
which under ordinary circumstances would be 
impossible. 
Indications.-The operation is indicated in cer- 
tain degrees of contracted pelvis. Unless the child 
is below the average size, it should not be at- 
tempted if the true conjugate measures less than 7 
cm. Ordinarily, it would not be necessary with a 
conjugate above 8 cm. A rigid, nondilatable cervix 
would contraindicate the operation, as would also 
a narrow, contracted vagina. Marked varicose 
condition of the veins about the symphysis and 
vulva might give rise to dangerous hemorrhage. 
Technic.-The steps of the operation are as 
follows: 
1. The patient is thoroughly prepared for the 
operation, anesthetized, and placed in the lithot- 
omy position. 
2. A metallic catheter is passed into'the urethra 
and pressed downward and to the right, so that 
injury to this structure may be avoided. 
3. An incision, about 2 inches in length, is made 
in the median line just above the symphysis. 
4. The incision is carried down through the 
fascia and the attachments of the recti muscles, 
separated sufficiently to permit the introduction of 
the index-finger along the posterior surface of the 
symphysis. 
5. Using the left index-finger as a guide, the 
Galbiati knife is hooked under the symphysis, in- 
clined a little to the left, and by a sawing or rocking 
movement the joint is divided from below upward 
and from within outward. If the joint does not 
separate, the knife should be reintroduced and the 
subpubic ligament divided. 
6. To prevent too great a separation of the joint, 
the trochanters should be supported by assistants. 
Hemorrage is usually profuse, but can be controlled 
by plugging the wound with gauze. 
7. The catheter is now removed, and the child is 
delivered with forceps if engagement has occurred; 
by version, if it has not. 
8. The wound is now united with a few inter- 
rupted sutures of silkworm-gut, and a firm pelvic 
binder is applied. 
The patient remains in bed for 4 or 5 weeks. 
To secure union of the joint, she should remain 
upon her back with the limbs closely approximated. 
This position is best secured by a specially arranged 
trough-shaped bed, or hammock, or by the use of 
sand-bags extending from the axilla to the ankle. 
Prognosis.-The maternal mortality of sym- 
physeotomy at the present day is about 10 percent 
On account of the close approximation of the limbs 
it is difficult to keep the parts perfectly free from 
the discharges. This, and the fact that the wound 
is so close to the genitalia, favor the development of 
sepsis after the operation. There may be some 
difficulty in walking, but this soon disappears. 
The rapid extraction of the child also favors injury 
to the soft parts. The infantile mortality is about 
20 percent. 
SYNCOPE.-A swooning or fainting. A partia- 
or complete temporary suspension of the functions 
of respiration and circulation. 
Causes.-Syncope may be due to a condition 
which interferes with the action of the heart, either 
intrinsically, through the nervous system, through 
the blood, or through more than one of these 
channels. 
When intrinsic, cardiac complications, espe- SYNCOPE 
SYPHILIS 
cially fatty degeneration, may be causative. Com- 
pression of the heart from diseased conditions or 
by tight articles of dress, excessive natural or arti- 
ficial heat, or certain drugs or poisons may be pro- 
vocative of syncope. The most common nervous 
cause is uncontrolled emotion, such as fear, joy, or 
grief. The reflexes are also sources of provocation, 
from the effects of irritant or intestinal poisons, 
worms, scybala, etc. Of the causes connected 
with the blood, that of hemorrhage is the most 
common, while chronic anemia and chlorosis are 
often accompanied by it. 
Fainting also occurs from hunger and starvation, 
railway shocks, grief, painful lesions, and cerebral 
concussion. Fainting from overheated air is partly 
due to the direct effect of heat upon the circulation, 
partly to interference with respiration, and partly 
to the effect on the heart of carbonic acid and 
other excrementory products. 
The duration of the several stages of shock 
varies from a few seconds to hours. 
Prognosis.-The most common termination is 
recovery, but death may occur. 
Fatal syncope has occurred at the height of an 
attack of diphtheria and in chronic valvular heart- 
disease, while there is a tendency to syncope in 
myocardial disease. Death by syncope may follow 
hemorrhage or may be due to thrombosis or em- 
bolism of the pulmonary artery or to pneumo- 
thorax. Sudden and fatal syncope from serofibrin- 
ous effusion in acute pleurisy may be induced 
by such slight exertion as getting out of bed. 
Diagnosis.-Syncope must be differentiated 
from apoplexy, from concussion of the brain, from 
shock, and from poisoning of many kinds, including 
poisoning by gases and by alcoholic liquors. The 
character of the pulse will distinguish between those 
conditons which have their origin in the brain 
and those from poisoning (unless due to poisoning 
by heart depressants). Hysteric faints, not car- 
diac, are readily diagnosed by the pulse, which is of 
good volume and force in these cases. Shock 
usually produces a degree of syncope. See Shock, 
Coma (Treatment). Two indications are to be 
met: (1) The removal of the cause of the faintness, 
and (2) the restoration of the action of the heart. 
The patient should be placed flat on the back, and all 
neck or chest constriction, from clothing or other- 
wise, removed. The atmosphere should be as 
pure as can be obtained by throwing open windows, 
doors, etc., or by removal to the open air. Any 
causative hemorrhage must be checked, and any 
other cause must be removed. Cardiac stimu- 
lants are to be employed. Alcohol, as brandy, 
whisky, or strong wine, may be given, and am- 
monia or smelling salts should be inhaled. Cold 
water may be dashed over the face. Amyl nitrite 
is very efficacious in anemic subjects. Atropin hy- 
podermically, 1/100 to 1/60 of a grain, is a valuable 
remedy. The oil of cinnamon is a powerful stimu- 
lant. Ticture of nux vomica in 5-minim doses is of 
benefit in extreme cases of cardiac syncope ap- 
proaching heart failure. The compound tincture of 
lavender is stimulating and effective. Galvaniza- 
tion to the pneumogastric nerve, if practicable, is 
recommended, but still better is the electric brush 
swept over the abdomen and chest. Artificial 
Respiration (q. v.) is not to be neglected. Most 
cases will revive spontaneously. 
SYNDACTYLISM.-See Webbed Fingers. 
SYNOVITIS.-See Joints (Diseases), Joints 
(Injuries). 
SYPHILIS. Synonyms.-Lues venerea; morbus 
gallicus; pox; " bad disorder." Fr., Vgrole. Itai., 
Sifilide. Ger., Lustseuche; Krankheiten der Fran- 
zosen. Span., Sifilis. Swed., Radezyge. 
Definition.-Syphilis is a general infectious 
disorder, transmitted from one individual to an- 
other both by contact and inheritance, chronic in 
course, and displaying a more or less determinate 
sequence involving one or several of the organs of 
the body. It is classed with the infective granu- 
lomata, and it is due to the toxic effect of the in- 
vasion of the bodily tissues by a morbific germ. 
Etiology.-The Spirochaeta pallida or treponema 
pallidum of Schaudinn is in all probability the cause. 
This work of Schaudinn has been confirmed by 
Metchnikoff and other observers. Schaudinn con- 
siders that the spirochaet pallida (treponema pal- 
lidum) belongs to the protozoa rather than to the 
bacteria and therefore must not be classed with the 
spirilla. It is found in the primary and secondary 
lesions of acquired syphilis and in the organs of a 
The Spirochaeta refringens is the larger and more darkly 
stained organism, while the lightly stained and more delicate 
parasite is the Spirochaeta pallida (Treponema pallidum). 
From a chancre stained with Wright's blood stain.-(Hirsch- 
by Rosenberger.) 
congenitally syphilitic child, and has been demon- 
strated in the blood stream. For its inoculation a 
raw surface or abrasion is required. The infection 
is usually transmitted through the secretions of the 
primary or secondary lesions, but sometimes 
through the blood of the syphilitic patient. It is 
probable that the tertiary lesions are also capable of 
conferring the disease. Normal secretions unless 
contaminated with secretions of the lesions are not 
infectious. The disease may be transmitted, 
however, by the spermatozoa or ova of syphilitic 
patients. 
Though the majority of cases of acquired syphilis 
result from sexual intercourse, the infection 
may be conveyed by drinking utensils, infected SYPHILIS 
SYPHILIS 
hands, lips, or by handling infected patients. The 
syphilitic child may infect the wet-nurse. Rarely 
the disease has been acquired by vaccination. 
The Spirochaeta Pallida.-This organism does not 
readily take up anilin dyes. A reliable stain for it 
is the Giemsa stain, freshly prepared: 12 c.c. of eosin 
solution (2.5 c.c. of 1 percent eosin solution in 
500 c.c. of water); 3 c.c. of a 1 to 1000 aqueous 
solution of azur I; 3 c.c. of a 0.8 to 1000 aqueous 
solution azur II. One drop of this solution added 
to 1 c.c. of water is used as the stain, the speci- 
men being kept in the stain for 18 hours. 
The Wassermann Reaction.-The serum diag- 
nosis of syphilis depends upon certain principles. 
If the washed red corpuscles of the sheep (antigen) 
are added to heated serum of a rabbit, pre- 
viously immunized with washed red corpuscles of 
the sheep (amboceptor), and fresh guinea-pig 
serum (complement) thus forming the "hemolytic 
series," hemolysis occurs. Bordet and Gengou 
showed that when emulsions of bacteria are mixed 
with inactivated serum and complement, hemo- 
lysis does not take place by reason of the anchorage 
of complement to the bacteria which prevents union 
of the red cell and complement through the am- 
bocepter. This phenomenon has been applied 
by Wassermann to the diagnosis of syphilis. 
As in the immunization of the rabbit, so in syphilis, 
amboceptors are formed. When the blood serum 
of the monkey, made inactive or immune by pre- 
vious syphilitic infection, was added to human 
syphilitic serum, no hemolysis occurred, showing 
that the monkey serum must have contained 
antibodies. 
Method.-To the syphilitic antigen (extract of 
syphilitic organs) are added (1) the complement 
(fresh guinea-pig serum), (2) the suspected 
serum heated, (3) the amboceptor (heat-inactiv- 
ated rabbit's serum), (4) the washed red cor- 
puscles of the sheep, and the mixture is subjected 
to the action of incubator temperature. No hemo- 
lysis occurs by reason of the complement having 
been absorbed in the hemolytic series, the anti- 
gen and the serum tested being homologous. 
Such reaction is called positive. 
The Noguchi Modification.-Recently Noguchi 
has modified this reaction by using human instead 
of sheep corpuscles in the hemolytic series. He has 
also introduced test papers saturated with antigen, 
complement and amboceptor. His method is as 
follows: An antigen paper is applied to a definite 
quantity of the suspected human serum and fresh 
guinea-pig serum is added. After being subjected 
to incubator temperature, it receives the addition 
of the hemolytic amboceptor paper and a definite 
quantity of washed human blood corpuscles. See 
Luetin Reaction. 
Chancre (Initial Lesion, or Sclerosis).-A chancre 
is a modification of the sound or pathologically 
altered skin or mucous membrane occurring after 
syphilitic infection, and displayed after an in- 
cubation period, characterized by a circumscribed 
sclerosis and accompanied by an enlargement and 
induration of neighboring glands. The sole con- 
stant characteristics are: (1) An incubation pe- 
riod preceding its appearance-averaging between 
10 and 30 days, ordinarily between 21 and 26 
days, called the period of first incubation; (2) 
a sclerosis of the base of the lesion; (3) primary 
adenopathy, an enlargement and induration of the 
glands in nearest anatomic relation to the chancre. 
Every such initial lesion means a syphilis, mild 
or severe, actually present. Chancres may be 
represented at one time or another by every 
recognized lesion of the cutaneous surface, in- 
cluding the superficial erosion, the oftenest ignored 
and yet the commonest of chancre symptoms; 
the papule, the common result of inoculation of 
the skin as distinguished from that of the mucous 
surface; an ulcer, the result of local irritation, 
which may be shallow or deep. Mixed chancre 
exhibits at the outset all the features of the 
chancroid, but later becomes specifically indurated 
at the base, and is followed by a general syphilis. 
Another mixed variety is the chancre of syphilitic 
origin later infected with microorganisms. Persons 
infected with syphilis have usually but one attack 
in a lifetime, and most, if not all, of the so-called 
chancres of the syphilitic are without question 
gummatous. The initial lesion may occur upon 
any portion of the body surface, the genital region 
being most often involved merely because of the 
frequency of transmission during the sexual act. 
Extragenital chancres are not a rare occurrence. 
The lesions are seldom multiple; most often they 
are single, differing from the soft chancre, which 
spreads from one point to another on account of 
the autoinoculability of its discharge. 
The induration of the initial lesion is one of its 
constant features. This may precede or follow 
the evolution of the chancre, or it may first be 
observed at the moment of detection of the sore 
itself; but sooner or later it wholly disappears. 
From the number or appearance of the lesions no 
prognosis can be made as to the severity or mild- 
ness of the ensuing disease. Chancres may or 
may not persist until the evolution of the systemic 
disease. They seldom leave scars, on account 
of their indisposition to undergo ulceration. 
Diagnosis.-The chancroid is usually a pustular 
lesion, is never indurated, is usually multiple; the 
adenopathy is usually represented by a single bubo; 
and the secretion is indefinitely auto-inoculable. 
Herpes progenitalis lasts but a few days, is 
essentially vesicular, and the cause may often be 
determined without great difficulty in systemic 
derangement. 
Balanitis is always short-lived, and yields 
readily to treatment; produces itching and burn- 
ing; there is no induration or glandular com- 
plication and no ulceration. 
Venereal warts are never indurated, rarely ulcer- 
ate, survive for long periods of time, and show no 
adenopathy. 
Epithelioma occurs commonly after middle life, 
is of long duration, inactive, and noninflammatory. 
Molluscum epitheliale is never ulcerated, in- 
durated, inflammatory, or the seat of evidence of 
any acute process; and cheesy masses can be ex- 
pressed from the orifice of the sebaceous gland 
involved. 
Lichen planus presents lesions always papular, SYPHILIS 
SYPHILIS 
never indurated or ulcerated, or accompanied 
by glandular enlargement; and it is usually 
multiple. 
Treatment.-Strict observance of cleanliness, in 
order to avoid any irritation of the sore, must be 
observed. Cleansing with warm water and hot 
borated solutions, followed by bland dusting- 
powder and the avoidance of salves and unguents, 
are the principal points to be observed. Mercury 
should be administered by the mouth when the 
diagnosis is satisfactorily established, but not be- 
fore. The adenopathy ordinarily requires no treat- 
ment, unless painful, when frequent ablution with 
hot water is the best and most grateful method of 
treatment, followed, when needed, by a weak 
mercurial salve well rubbed into the overlying skin. 
Division of constitutional syphilis into primary, 
secondary, and tertiary stages is now abandoned 
or largely modified, there being ordinarily no such 
definite demarcation in its manifestations. The 
majority of syphilitic histories may be traced 
within the four following divisions: 
1. Benignant syphilis with mild and transitory 
symptoms. In these cases a slight efflorescence 
upon the abdominal surface, a few days of malaise, 
and the disease is at an end, irrespective of any 
treatment whatever. This is rare. 
2. Benignant syphilis with relapsing or persis- 
tent superficial symptoms. This occurs in a 
large number of all cases occurring in the white 
race. Typical chancres are followed by superficial 
lesions without the production of any permanent 
results of the process. Patients of this large class, 
as a rule, entirely fail to exhibit symptoms of 
the type described as "tertiary." 
3. Malignant syphilis with relapsing or persistent 
profound symptoms. The malignancy of these 
cases is declared in the deterioration of the tone 
of the system, in the production of cachexia, in 
the production of gummata, which resolve under 
appropriate treatment; or, when degeneration 
occurs, the repair is either good, or the damage 
resulting is so slight as not to interfere with bodily 
health. In this class the best results of treatment 
are exhibited. 
4. Malignant syphilis with relapsing or pro- 
found lesions that are ultimately destructive. 
Here the disintegrating and ulcerating gumma 
destroys whatever tissue is attacked, and at times 
pushes its destructive forces to a fatal result. 
Syphilis, however, often mutilates, but rarely 
kills. In the majority of malignant cases the 
rapidity of progress of the malady is conspicuous. 
The determining influences that result in these 
divergences are of the highest importance: First, 
a soil rendered favorable by other diseases or by 
malnutrition; second, neglect of early and proper 
treatment. The implantation of the germ of 
syphilis upon a system contaminated with tuber- 
culosis, struma, and such cognate disorders as 
rickets is much rarer than is generally supposed. 
The Evolution of Syphilis Subsequent to the 
Chancre.-The signs of a gradual intoxication 
are progressively apparent. The skin assumes a 
peculiar hue; there are often rheumatic pains, 
headache, backache, lassitude, neuralgia, and in 
some cases jaundice. The number of the red 
blood-corpuscles decreases and the leukocytes 
increase. Thermal variation may be absent or 
may be either slight or pronounced. Fever is 
more often observed in the cachectic and weak 
than in the strong. The lymphatic system exhibits 
characteristic changes; the glands become enlarged, 
soft, and voluminous, as distinguished from the 
densely indurated buboes accompanying the 
chancre. At a given moment this may be the sole 
appreciable symptom. They are usually painless 
and have no tendency to degenerate. Resolution 
is by the ordinary absorptive process. Syphilitic 
cachexia may occur either'early or late, may be 
produced solely by the disease, and may be relieved 
greatly by properly directed medication, and may 
also be induced or aggravated by the injudicious 
employment of mercury. 
Syphilis of the Skin.-A study of the syphilo- 
derms is a study of the changes impressed by the 
infective process upon the simple manifestations 
of all skin-diseases. The early cutaneous symp- 
toms are usually symmetric, but as the disease 
progresses, they exhibit a greater tendency to 
assymmetry. Although the terms " copper-col- 
ored" and "raw-ham tint" have been employed to 
designate the special hues of the syphilitic exan- 
them, there is displayed no color which may not at 
times be recognized in nonsyphilitic subjects; but 
the color with the other picture presented is 
usually highly suggestive. Multiformity is a 
characteristic of syphilis shared by but few other 
maladies. The arrangement of the syphiloderms 
in groups having the outline of a circle, either 
complete or in segments, is also highly distinctive. 
Itching and pain are ordinarily absent, but in some 
lesions, particularly in condylomata, the itching 
may be severe. Situation modifies the expression 
of the local manifestations. Pustules are often 
seen upon the scalp and on the face; papules, over 
the neck and brow; secreting lesions, around the 
mucus-outlets of the body. Papules are usually 
ham-colored, and have a tendency to scale at the 
apex. Tubercles are generally grouped, and tend 
to ulcerate and to crust. The crusts are usually 
bulky. Scales are commonly thin, and of a dirty 
whitish hue. Ulcers have a soft base, undermined 
edges, and a sloughing floor with purulent or 
hemorrhagic secretion. Pustular lesions are usu- 
ally, if not always, due to secondary infection with 
pyogenic microbes. Scars, when recent, are 
generally pigmented; but when old, are of a dead 
white shade, with flaky, wrinkling surface. 
Classification of the Syphiloderms.- 
1. Macular 
(a) Pigmentary. 
(b) Erythematous. 
(c) Purpuric. 
(a) Miliary. 
(6) Lenticular. 
(a) Mucous patches. 
(b) Condylomata. 
2. Papular. 
dry. .. 
moist.. 
3. Pustular.. . 
(a) Miliary. 
(b) Lenticular. 
4. Tubercular. 
5. Gummatous. SYPHILIS 
1. Macular Syphiloderms.-The pigmentary va- 
riety occurs as a distinct network of macules, the 
pigment being gradually diminished, commencing 
in the center of each deposit, until at last it is 
wholly removed. This condition is most common 
in the earlier stages of the malady, and frequently 
in the uncleanly and negligent. The normal 
quantity of coloring-matter may remain after 
involution, or a true vitiliginous atrophy of the 
pigment may follow. The erythematous syphilo- 
derm is the most common, the most benign, the 
earliest, and the most classic of the skin symptoms 
of the disease. It may be limited to the regions 
covered by the clothing, and it is for the most part 
unaccompanied by any subjective sensation. It 
usually appears between the sixth and seventh 
week, and is of a dull shade of yellowish-red, fading 
under pressure. As a rule, the eruption fades 
under treatment in a week or 10 days. The cir- 
cinate arrangement may be conspicuous. Pur- 
puric lesions are most commonly seen in the 
inherited form of the disease, though they are not 
rare in adults. It must be remembered that iodid 
of potassium is capable of producing purpura of 
the skin. When due directly to the disease, and 
not to the drug, it is a somewhat grave symptom. 
2. Papules.-Papules are among the most com- 
mon of the syphiloderms. They vary largely, 
according to the site of each lesion. Upon the 
exposed surface of the skin they are usually dry 
and squamous; upon apposed surfaces they enlarge, 
flatten, and secrete; upon mucous surfaces they 
form a mucous patch. Dry papules may be 
miliary, or from pinhead-sized to bean-sized or 
larger. When resolution occurs, the papule flat- 
tens to the level of the skin, leaving a pigmented 
macule, which is apt to be exceedingly rebellious to 
treatment and slow to disappear. When develop- 
ing upon the palms and the soles, papules have a 
characteristic aspect and career, and will not 
readily be confounded with other disorders. The 
papule in this situation produces a cirumscribed 
thickening of the skin, which scales in the epider- 
mal portions, and in extreme cases induces an 
ulceration in the region of each papular thickening. 
Papules sometimes linger for years as almost the 
sole symptom of the disease. The moist papule 
upon the mucous membrane becomes the mucous 
patch, which is pathologically identical with the 
moist papule of the skin. Moist papules occur on 
the skin in regions where the conditions are similar 
to those of mucous membranes with respect to heat, 
moisture, and the apposition of surfaces. On the 
mucous membranes they are moist, secrete a thin 
mucous, are offensive, and their secretion is highly 
contagious. Occasionally they develop into large 
vegetating masses; at other times they ulcerate. 
Condylomata are hyperplastic, moist papules, and 
are either flat or pointed. The flat condyloma is 
seen only in syphilitic subjects, and is a distinct 
symptom of the disease. Condylomata are found 
most frequently about the anus, and are usually 
the seat of a tormenting pruritus. The pointed 
wart is seen not only in syphilis, but in other vene- 
real diseases as well. Condylomata are often com- 
pared in appearance to a cockscomb. 
3. Pustular Syphiloderm.-Under this title are 
included all fluid-containing lesions of the skin- 
vesicles, pustules, and bullae. When they appear, 
some accident has intervened to divert the career 
of the papule into singular channels-such as 
medicaments, pus microbes, neglect, filth, or para- 
sites. They are extremely rare in properly treated 
patients. The lesions may be miliary, pinhead- 
sized to bean-sized, or confluent. They have 
frequently been mistaken for the lesions of small- 
pox, which they greatly resemble. The cicatrices 
left from the smaller lesions are rarely conspicuous; 
but from the larger and confluent sores the scars 
may be indelible. In the confluent variety there is 
distinct circular grouping of the pustules, and an 
ulcerating ring forms. There may be but few such 
lesions forming a single group. When repair en- 
sues, the crusts fall, the ulcers granulate, and 
cicatrization concludes the history. 
From varicella and variola this manifestation of 
the disease may be distinguished by the fever, by 
the activity of the lesion, by the umbilication and 
multiplicity of the sores; from acne, by the region 
invaded, the latter being usually limited to the 
face and upper trunk. 
4. Tubercular Syphiloderm.-The tubercle is 
with difficulty distinguished from a gumma; 
clinically and pathologically there is little differ- 
ence between the two lesions. Tubercles, ordi- 
narily more superficial, are more apt to resolve, 
develop at an earlier period, are more numerous, 
and are more commonly grouped. Tubercles 
ordinarily occur after a lapse of from 2 to 10 years. 
They are firm nodules, copper-tinted, ordinarily 
arranged in portions of circles. They may be dry 
or atrophic, resolving beneath an unbroken epi- 
dermis, leaving a pigmented macule that fades and 
leaves an indented scar. They may be ulcerative, 
the upper portion of the small tumor being de- 
stroyed, involving either the small circumscribed 
area or producing broad, palm-sized, and larger 
destruction of tissue. 
5. Gummatous Syphiloderm.-Gummata of the 
skin are at first uncolored elevations; later they 
become livid, as the integument becomes thinned 
to a point where bursting of the contents occurs 
through its envelope. They are usually late 
lesions, occurring from 2 to 5 years after the 
chancre, but may develop within a few months. 
They are most common on the leg; also common 
on the shoulders and back. The bones of the part 
invaded frequently suffer, causing extensive 
mutilation, especially about the face. Not the 
least conspicuous among the distinctive features 
of these severe ravages of syphilis is the extra- 
ordinary extent to which, when properly treated, 
repair ensues-a distinction of the highest value 
in respect to diagnosis. 
Serpiginous and vegetating syphiloderms are 
conditions due to peculiar forms assumed by 
lesions previously mentioned, and are not special 
cutaneous expressions of the disease. 
Syphilitic Affections of the Hair.-Syphilitic 
alopecia may be due to the action of the disease 
either upon the nutrition of the hair or directly 
upon the scalp. The most common form, how- 
SYPHILIS SYPHILIS 
SYPHILIS 
ever, produces no structural change in the integu- 
ment. The loss of hair may be partial or general, 
affecting at times only the hair of the scalp; at 
other times, that of the entire body. As a rule, 
bare patches in areas from fingernail-size to palm- 
size occur upon the scalp. The lack of symmetry 
is noticeable; the hairs of one eyebrow for example 
disappearing while the other eyebrow remains 
intact. When the integument undergoes struc- 
tural changes, the hair follicle itself is frequently 
destroyed, preventing a return of the hair; whereas 
in the simpler form already mentioned, the loss is 
not without remedy. 
Syphilitic Affections of the Nail.-Syphilitic 
onychia and paronychia are not infrequent, and 
may coexist. There may be superficial exfolia- 
tions, fissures, or ulcers; the, nail fold, the nail 
groove, or the matrix may be the seat of deep and 
ill-defined infiltration. The course is commonly 
indolent; at times, exceedingly painful. The odor 
is highly offensive and the secretions are conta- 
gious. The nail may be lost entirely or partially, 
and the new-formed nail may be correspondingly 
misshapen. This complication is often a portent 
of a grave syphilis, and is likely to occur in middle- 
aged patients with weakened constitutions. When 
the change is confined to the nail itself, there may 
be either atrophy, and a characteristic worm-eaten 
appearance, or hypertrophy with perceptible 
thickening. 
Syphilis of the Mouth and the Tongue.-These 
lesions correspond strictly to those already studied 
as of occurrence in the skin, modified simply by 
peculiarities of site and by such habits as using 
tobacco, holding pipes, cigars, and toothpicks in 
the mouth, and by the drinking of hot or highly 
spiced liquids and the use of salted foods. Carious 
teeth pressing upon the tongue and cheeks are also 
frequently productive of such lesions. The macu- 
lar syphiloderm produces an area of vivid or dusky 
redness, which may result in erosion or ulceration, 
but which disappears under proper treatment. 
The papular syphiloderm is here represented by 
the mucous patch of varying size, slightly raised 
above the general level. These patches are usu- 
ally painful, and are succeeded by superficial ero- 
sion and ulceration, particularly at the angles of 
adjacent surfaces, such as the outer angles of the 
lips, where both the mucous and cutaneous sur- 
faces may be involved. Gummata occur in the 
tongue, usually single, breaking down rapidly into 
ragged ulcers. Usually, these lesions are present 
in persons who are large users of tobacco, especially 
in chewers. In severe cases the results may be 
equaled only by the extensive ravages of cancer 
in the same region, but the repair wrought by 
skillful treatment is extraordinarily happy in 
results. 
Syphilis of the Nasal Passages.-In this tract 
chancres are rare. The lesions present are mucous 
patches and gummata. The destruction is often 
extensive, the hard and soft palates being per- 
forated or destroyed or passages being obliterated 
by cicatricial occlusion. The disease may thus 
extend to the meninges of the brain. Mucous 
patches and gummata also occur in the pharynx, 
producing grave destructive results when the bone 
is invaded. In the larynx typically developed 
mucous patches are rarely seen, but erosions and 
superficial ulcers may be discovered over the epi- 
glottis, the vocal cords, and other parts on laryngo- 
scopic examination. Later, gummatous changes 
may produce more serious accidents. The result- 
ing ulcers leave cicatrices which may prove harm- 
less or may draw together the walls of the larynx 
or fasten the epiglottis to the tongue or to the 
pharyngeal wall. The chief symptoms recognized 
without laryngoscopic examination are the hoarse 
voice, cough, dyspnea, and symptoms due to 
imperfect aeration of the blood, varying from the 
mildest to the severest distress. In the great 
majority of cases the prognosis is favorable, restora- 
tion of the voice being secured even after well-nigh 
complete aphonia for months or years. In the 
trachea and bronchi syphilitic lesions resemble 
those upon the structures immediately above. 
The more deeply syphilitic lesions spread toward 
the lungs, however, the greater is the gravity. 
Syphilis of the Bones.-Most of the changes in 
bone are due to gummatous deposits, either in the 
periosteum, between it and the osseous tissue, 
within the bone substance, or in the medulla. The 
lesions are commonly multiple, forming tumors 
varying greatly in size, which are exceedingly 
painful, especially at night. In fact, the noctur- 
nal exacerbations are considered diagnostic, and 
are due to the warmth engendered by the bed- 
clothing, which increases the tension between the 
tense periosteum and the unyielding mass of the 
osseous tissue. The course may be either com- 
plete involution or degeneration by softening, 
the tumor breaking at the center, leaving an ulcer 
with exposed bone at the base. 
Syphilis of the Joints.-Synovitis and arthritis 
may involve one or more joints. The articula- 
tions are tender, painful, and hot, motion is limited, 
and there are generally pyrexial symptoms. Ter- 
mination may be by resolution, by ankylosis, or 
by destruction of the joints. The knee and the 
sternoclavicular and scapuloclavicular joints are 
chiefly involved. 
The tendons and tendinous sheaths may be 
involved in gummatous processes; the aponeu- 
roses may also be involved. In the muscles gum- 
matous infiltration may involve the muscle bun- 
dles, producing pain, sometimes permanent con- 
tracture, or atrophy; the latter condition may also 
result from involvement of the nerves supplying 
the muscle. Syphilitic pericarditis is rare. Gum- 
mata have been found postmortem in the septa and 
substance of the heart. Fibrous myocarditis of 
syphilis is due to invasion of the coronary arteries. 
Aneurysm of the heart has been recognized as 
directly due to syphilis, and also to the indirect 
results of its cachexia. The blood-vessels may be 
affected by a fatty metamorphosis, resulting in the 
formation of aneurysmal pouches; or the endo- 
thelium of the vessels may be thickened, producing 
an endarteritis obliterans. Gummatous peri- 
arteritis has also been observed in both the circum- 
scribed and diffuse forms. 
Considerable difficulty in discriminating between SYPHILIS 
SYPHILIS 
gumma and tubercle of the lungs has obscured the 
characteristic features of syphilitic disease. The 
latter, however, is found in the posterior and 
lower lobes of the lung oftener than in its apex; 
and on section the lung closely resembles the condi- 
tion seen in simple pneumonia, its substance being 
firm and grayish or reddish. The absence of leu- 
kocytes is conspicuous. The absence of tubercle 
bacilli is, of course, of the greatest value in estab- 
lishing a diagnosis. 
Syphilis of the intestinal canal is rarely encoun- 
tered save in the anorectal pouch, where gumma- 
tous deposits are found. Gummata are sometimes 
found in the liver of the subjects of syphilis, near 
the capsule or deeply set. The effect is frequently 
like that occurring in cirrhosis. It is rare that 
symptoms pointing unmistakably to hepatic 
involvement are displayed during life. Syphilis 
of the spleen and pancreas is exceedingly rare. 
When these organs are involved, gummatous 
deposits of varying size are found. 
In the anal region chancres are often mistaken 
for piles. The early lesions are usually flat papules, 
in consequence of heat and moisture becoming con- 
dylomata and mucous patches, which are rapidly 
developed. Syphilitic ulcers of this region are 
circular in outline, and have undermined walls and 
pultaceous floors, contrasting with the sharply cut, 
irregularly outlined walls and deep floors of tubercu- 
lous invasion. 
Syphilitic stricture of the rectum, whether re- 
sulting from a proctitis leading to the specific com- 
plication, or from gummatous changes in the lower 
segment of the rectum, is more common in women 
than in men, and constitutes one of the most for- 
midable of the complications of the disease. The 
lumen of the gut is interfered with in various grades, 
from those due to bands, bridles, or constricting 
rings around the organ to the severe grades in 
which the rectum is converted into a tortuous 
channel, interrupted by knobs and bridles and 
almost completely occluded. Relief is difficult in 
the absence of surgical interference, which may 
require division of the strictured portions of the 
gut by the aid of the electrocautery (often eventu- 
ally valueless), by the production of an artificial 
anus in the groin, or by complete excision of the 
entire neoplasm. By the use of bougies relief may 
be secured for a time, internal treatment proper to 
the malady being at the same time instituted. 
Gummata of the rectum may be single, multiple, 
or diffuse, occurring frequently in an annular form, 
producing the large majority of all rectal strictures. 
Syphilis of the Genitourinary Organs.-Gum- 
mata developing in the corpora cavernosa are 
represented by nodules or, very rarely, by annular 
bands. Deep deposits in the urethra, as well as in 
the prostate gland and seminal vesicles, are quite 
rare. The epididymis and cord are occasionally 
invaded. The globus major and, more rarely, the 
globus minor become indurated, inelastic, and at 
times somewhat tender. Syphilitic orchitis is a 
frequent complication of late syphilis, the change 
occurring frequently without the knowledge of the 
patient. The gummatous infiltration may be 
circumscribed or diffuse, or there may be dense in- 
duration, suggesting the firmness of a marble. The 
size of the glands may be unaltered, or they may be 
either enlarged or shriveled. In other cases degen- 
eration and bursting of the gumma result. Gum- 
matous lesions of the vulva are not uncommon, 
while the vagina is rarely invaded. The cervix and 
os uteri may be the seat of either primary or con- 
secutive lesions, which must be carefully differen- 
tiated from epitheliomata, polypi, and chancroids. 
The bladder is rarely involved. An acute nephritis 
due to syphilis may occur within a few months 
after infection, but recovery usually follows vigor- 
ous treatment. In late lesions lardaceous degen- 
eration is characteristic. When both organs are 
involved, the prognosis is grave; but good recovery 
ensues frequently when but one organ is affected. 
Syphilis of the Nervous System.-Changes in the 
nervous system due to syphilis may result from 
the effects of the disease upon the osseous system, 
upon the meningeal coverings of the nerves, upon 
the nerve-cells and fibers, or upon the vessels 
furnishing nutriment to the nerves. A fatal issue 
in syphilis can more often be ascribed to the ner- 
vous than to any other system. Gummatous de- 
posit in the cortical portion of the brain is perhaps 
the most common involvement. An obliterating 
endarteritis may cause thrombosis and subsequent 
occlusion, or small aneurysms with subsequent 
rupture and cerebral hemorrhage. The symp- 
toms are headache, with nocturnal exacer- 
bation, possibly aggravated by pressure over 
certain points. The capriciousness and multi- 
formity of the surface symptoms, however, are 
striking. Monoplegic or hemiplegic attacks in- 
dicate affection of the larger ganglia. Lesions 
of the crus, of the pons, and of the medulla 
are indicated by symptoms similar to those pro- 
duced by other lesions of the same areas. 
Syphilis of the cord may produce bilateral spastic 
paralysis of the lower extremities, exaggera- 
tion of tendon-reflexes, contractures of muscles, 
rectum and bladder symptoms, and, in some cases, 
severe pains in the lower limbs. Syphilis is, with- 
out question, a precedent fact in a large majority 
of all cases of tabes and paralytic dementia. 
Syphilis of the Eye.-Any of the ocular appen- 
dages-the eyelids, the lacrimal gland, the canalic- 
uli, the sac, and the nasal duct-may be involved in 
any one of the early or late manifestations of 
syphilis. Syphilitic iritis is the most common of all 
luetic affections of the eye. The subjective 
symptoms are photophobia, lacrimation, deep- 
seated pain, and imperfect vision. There are 
noticed change of color, irregularity of the pupil- 
lary opening, sluggishness of the iris, and deep 
ciliary injection. The prognosis is good. Syphi- 
litic choroiditis is next in frequency. The symp- 
toms are clouding of the vitreous humor by specks 
on the membranes, diminution of ocular tension, 
pain, and amaurosis. Pure retinitis without choroid- 
itis is rare. The fundus is misty, the papilla is ob- 
scured, and the disc is encircled by a grayish retina. 
Exudation and hemorrhages may occur. The 
optic nerve may be affected either within or with- 
out the cranial cavity. Bilateral choked disc 
indicates an intracranial lesion. When but one SYPHILIS 
SYPHILIS 
eye is involved, the disturbance may be wholly 
within the orbit. Atrophy of the optic nerve may 
result. Syphilis of the ocular muscles is due not to 
a specific myositis, but to intracranial lesion. 
Implication of the bony walls of the orbit, causing 
pressure upon the nerve, may produce exophthal- 
mos and violent neuralgia. Abscesses may form 
and burst, leaving fistulous tracts to carious bone. 
Syphilis of the Ear.-The external ear may be 
the seat of any of the cutaneous lesions of systemic 
syphilis. The membrana tympani is rarely attack- 
ed. Most syphilitic affections of the middle ear 
result directly from disorders of the nasal pharynx 
and eustachian tube. 
Hereditary Syphilis.-Syphilis may be trans- 
mitted from progenitor to offspring as a strictly 
inherited disease. Colles' law points conclusively 
to the fact that syphilis of the child means syphilis 
of the mother, whether or not the mother betrays 
other symptoms of the disease. It cannot always 
be determined whether such women have been in- 
fected with syphilis directly, from their husbands, 
or indirectly, from the syphilitic contents of the 
uterus. If, however, the mother is without syph- 
ilis, the child commonly escapes. The period of 
pregnancy beyond which the mother cannot 
transmit her disease to her unborn child is not 
fixed. After the sixth month the child probably 
escapes. The question whether inherited syphilis 
can be transmitted to the third generation can, 
for the immense majority of all cases, be answered 
in the negative. The question respecting acquisi- 
tion of syphilis later in life by the subject of in- 
herited disease is to be answered in the same man- 
ner. A few cases have undoubtedly occurred in 
which the victim was not certainly protected from 
a second attack. See Luetin Reaction. 
Syphilis of the Placenta.-In some cases of un- 
doubted syphilis of the offspring the placenta has 
been found wholly free from morbid symptoms, 
while in other cases the villi are represented by 
gummatous masses, and the vessels of the cord 
have been more or less obliterated. It is a matter 
of importance to note that the liquor amnii of the 
woman bearing a syphilitic fetus is capable of com- 
municating the disease to the accoucheur. 
Symptoms of Hereditary Syphilis.-A series of 
pregnancies resulting in abortions, first at an 
earlier and later at a more advanced stage of 
gestation; these succeeded by one or more mis- 
carriages, and the latter by the birth of a mature 
child surviving but a few hours, furnishes atypical 
history of syphilis of the mother. Eventually, 
a child may be born apparently healthy at birth, 
but before the fourth month may develop symptoms 
of inherited disease. The mortality in these cases 
is between 60 and 90 percent. About seven- 
eighths of diseased infants exhibit symptoms 
of the inherited malady before the termination of 
of the third month. Children showing symptoms 
of the disease at or about the age of puberty 
have, in all probability, really betrayed evidences 
of syphilis in infancy that were overlooked. 
The cutaneous lesions in a fetus aborted as the 
result of syphilis are maceration of the skin and 
bullae filled with ill-conditioned serum. A viable 
child may be born with a specific exanthem more 
or less generally evolved. An infant under the 
average weight, weazened, yellow-tinted, snuffling, 
with an aged appearance,with blisters on the fingers 
and toes, a circlet of papules about the mouth or 
anus, with a feeble cry and obvious weakness, 
enables the practitioner to make a diagnosis at 
a glance. In these infants the syphiloderm may 
be macular, papular, or tuberculous. The nails, 
hair, glands, bones, and genital organs may 
be affected. The saber-blade deformity of the 
tibia is characteristic. The teeth, as described by 
Hutchinson, are characteristically notched, partic- 
ularly the central upper incisors. (See Teeth 
in Diagnosis.) The pharynx, larynx, trachea, 
and bronchi may be the seat of changes that may 
destroy the perichondrium or cartilages. The 
liver may be the seat of miliary or of larger sized 
and diffused gummata. The spleen is frequently 
enlarged. The kidneys may present evidences 
of lardaceous degeneration. The nervous system 
may suffer in any portion, resulting in mental 
states varying from feeble-mindedness to complete 
idiocy. With the exception of retinitis and optic 
neuritis, the eye and ear are subject to most of the 
disorders of the acquired disease. 
Treatment of Syphilis.-Attention to the general 
health far outweighs in importance the question 
of drugs. An ample supply of nutritious and 
digestible food; alcoholic beverages in wise dis- 
cretion, according to the judgment of the practi- 
tioner; daily sponging with salt water-cold, if the 
patient is vigorous-with rubbing with coarse 
towels afterward, are important aids to a favorable 
issue. The use of tobacco invites mucous patches 
in the mouth, as does any other irritation, such 
as the use of chewing-gum, constantly holding 
toothpicks in the mouth, and the presence of carious 
teeth. Diversion of the mind, outdoor living, 
care of weak eyes, of hernia, or of hemorrhoids, 
all have distinct value. Delay in instituting 
systemic treatment until the fullest recognition 
of the disease has been established in no way 
jeopardizes the future of the patient or his 
amenability to the later management of his 
malady. In fact, an early and frank efflorescence 
is an augury for good in an otherwise healthy 
subject. The length of time during which treat- 
ment should be kept up varies according to the 
health before infection, the management during 
treatment, the virulence of the infection, and the 
surroundings of the patient. Most patients 
practically recover after from 2 1/2 to 3 years. 
Mercury holds the most important place among 
drugs esteemed efficient both for the relief of the 
symptoms and for the radical cure of the disease. 
Its preparations, in the order of their value, are 
the protiodid, the bichlorid, the biniodid, the 
tannate, blue pill, calomel, and the gray powder. 
It is well to begin with an average dose of the 
metallic salt, to be increased according to indica- 
tions. The patient should gain in weight, and 
should digest his food with appetite and profit. 
The protiodid may be given in doses of from 1/10 
to 1/3 grain after each meal, combined with 
Vallet's mass or the citrate of iron and quinin. SYPHILIS 
Whenever such a course seems desirable, any 
one of the other preparations of the metal may be 
substituted for the protiodid; for instance, the 
bichlorid 1/60 to 1/12 grain; the biniodid, 1/50 to 
1/16 of a grain; the tannate, 1/2 to 1 grain; bluepill, 
1/4 to 1 grain; calomel, 1/10 to 1/4 grain; and the 
gray powder, from 1 to 5 grains. It is believed that, 
when all progresses satisfactorily, the patient who 
secures complete immunity from symptoms of his 
disease in the first half year does better when no 
remedy is administered save mercury. Other things 
being equal, he who has secured complete relief 
from syphilis without using the iodid of potassium 
has usually had either a mild or an exceedingly 
tractable form of the disease. 
Iron is administered with decided advantage to 
the great majority of all patients affected with 
syphilis, and should be used whenever not con- 
traindicated. The iron and quinin citrate, from 
3 to 8 grains before meals, or the muriated tincture 
of iron in combination with corrosive sublimate 
(of the latter, 1/60 to 1/30 grain after meals), may 
be used. 
Inunction of mercury has the excellent recom- 
mendation of sparing the stomach, and is also of 
advantage in grave cases or in cases of emergency; 
also when there are persistent lesions refusing to 
yield to internal medication. The ointment, 
in 50 percent strength, combined with lanolin 
or vaselin, should be rubbed in until it has practi- 
cally disappeared. Often it is desirable to give 
a course of 20 inunctions, after which the rubbing 
maybe suspended while other treatment is pursued, 
the inunctions being renewed until the entire 
number advised is completed. New areas of 
inunction should be selected on successive days 
in order to avoid dermatitis. Such a dermatitis 
is, however, rarely serious. When it really seems 
to demand treatment, a simple dusting-powder 
or Lassar's paste usually suffices. 
The mercurial vapor bath is both efficient and 
speedy, and in an emergency is capable of producing 
very rapid effects. Calomel or cinnabar, or the 
two in combination, may be selected. It is 
best given before bedtime, and should last for 
about half an hour. If debility is induced by the 
steaming, tonics, and even a generous glass of wine 
with the dinner, should be administered. 
Hypodermic injections are employed more fre- 
quently than formerly. Rapidity of effect, the 
sparing of the digestive tract, simplicity, and 
cleanliness are contrasted with its danger, its 
liability to produce abscesses at the site of injec- 
tion, cardiac and pulmonary symptoms after in- 
jection within a vein, considerable pain, exhaus- 
tion, and possible sudden death. If, nevertheless, 
the hypodermic treatment is selected, strict 
surgical cleanliness and asepsis are extremely 
important. Corrosive sublimate is usually em- 
ployed, dissolved in a few minims of water sus- 
pended in olive oil or emulsified, and in the strength 
of from 1/12 to 1/10 grain. The method has not 
as yet shown results that warrant its adoption as a 
routine treatment, its disadvantages rendering 
its general adoption improbable. The well- 
known toxic effects of mercury-including saliva- 
tion, dyspepsia, anemia, and symptoms simulating 
those of muscular rheumatism-must be carefully 
watched, for many symptoms popularly accredited 
to mercury are really due to the syphilis, and are 
wrongly imputed to the metal. 
Intramuscular injections have come into promi- 
nence in the last few years, the gluteal region 
being the preferable site. Of the soluble salts, 
the benzoate and the binodid of mercury are 
most frequently used; of the insoluble the sali- 
cylate, calomel and gray oil. 
Intravenous injections of soluble salts have 
proved valuable in the hands of some clinicians. 
See Intravenous Injection. 
Arsenic has recently been advocated, alone or 
alternately with mercury. Of the three forms 
which have recently come into favor atoxyl, 
soamin, and arsacetin (g. u.), the first has been 
found to produce optic atrophy. The second, 
soamin, too has been reported to be dangerous. 
Arsacetin, the most stable and least toxic is prob- 
ably the preferable drug. See Arylarsonates. 
Salvarsan ("606").-The latest addition to 
specific therapy is Ehrlich's synthetic arsenic 
compound, arsenobenzol (dioxydiamidoarseno- 
benzol dihydrochlorid) called "606," as it was the 
606th preparation tried. A single injection of a 
proper dose is reported to be as destructive to the 
Spirochaeta pallida as quinin is to the plasmodium 
malariae. Within a day or two one injection of 
the drug will kill all the spirochetes in superficial 
lesions such as mucous patches or primary lesions. 
The dose of "606" at present is from 0.45 to 
0.6 gram injected subcutaneously below the 
scapula. "606" is an unstable yellow powder 
put up in vacuum tubes to prevent its rapid 
oxidization in the air. In order to make the injec- 
tion painless-the acid solution resulting from the 
addition of water producing much pain-the drug is 
injected in the form of an alkaline salt (Alt) or, pref- 
erably, of a neutral base (Wechselmann'smethod). 
The neutral base is obtained by dissolving the 
dose to be given in 1 to 2 c.c. of sodium hydrate 
solution and then adding acetic acid, drop by 
drop. To the fine yellow precipitate-the base- 
that forms is added 1 to 2 c.c. sterile distilled water 
and then 1/10 normal sodium hydrate or 1 per- 
cent acetic acid, as required, until the reaction is 
exactly neutral to litmus. Ehrlich warns against 
the use of the drug in advanced disease of the 
heart or blood-vessels or in ocular disease in- 
volving the optic nerve. Attempts are being 
made to reduce to a minimum the toxicity of the 
drug. The latest improvement-Ehrlich's "hy- 
perideal" is claimed to be but one-third as toxic as 
the original. While there is not complete unani- 
mity on the byeffects of the drug, all the clinicians 
who have been testing it agree that it is not toxic 
to the human adult in doses of five to eight grains, 
and that it is a remarkable specific for syphilis. 
Intravenous injection is now being used; it is 
claimed that this method is painless, more power- 
ful in its effects upon the Spirochaeta pallida, allows 
of more accurate dosage, and is not followed by so 
many bad after-effects. 
Boehm's method of giving salvarsan intraven- 
SYPHILIS SYPHILIS 
SYPHILIS 
ously is described by Hirsch as follows: "Two 
graduated glass containers of 250 c.c. capacity are 
used. Into one is poured 150 to 200 c.c. of sterile 
salvarsan solution. The other is filled with a like 
volume of sterile saline solution (made with sterile 
distilled water and chemically pure sodium chlorid). 
The saline solution is allowed to flow out of the 
needle so as to expel all air from the tube. The 
stop-cock is now reversed, allowing the salvarsan 
solution to flow out of the needle, thereby expel- 
ing all air from its tubing. The stop-cock is now 
As soon as the needle has entered the vein, the 
rubber ligature is released by an assistant, the 
stop-cock of the needle is reversed, and the salvar- 
san solution flows through the needle into the vein. 
Hence there is no danger of any salvarsan solution 
getting into the subcutaneous tissues. The in- 
travenous injection must be given slowly, not less 
than ten minutes being spent in the process; and 
the solution must be quite warm when poured into 
the container so as to allow for its cooling when 
flowing into the apparatus; when it enters the vein, 
the solution should be about the temperature of the 
blood. An ideal intravenous injection is painless." 
lodin and its compounds stand next after mer- 
cury in value. The following are conditions in 
which it is wise to employ them: First, in attempts 
to resolve gummatous lesions; second, when the 
patient is intolerant of mercury, or when he cannot 
be made to gain in weight and appetite during 
youth; third, when the patient is being subjected 
to the action of mercury by external use; fourth, 
as an alternate medication to mercury. lodin is 
the one remedy earliest and most often resorted to 
by the ignorant, and it is the one which is last 
used, and then most effectively, by the expert. 
The dosage depends almost wholly on the emer- 
gency presented. Ordinarily, it may be adminis- 
tered in 5-, 10-, or 20-grain doses; but as high as 
600 grains, and even more, of the iodid of potas- 
sium have been given in 24 hours with favor- 
able results. It should be stopped or reduced 
upon the occurrence of any symptoms of iodism, 
constipation, or bladder trouble, or as soon 
as the immediate effect in view is secured. As a 
rule, the toxic effects of the drug speedily disap- 
pear when the exhibition of the remedy is sus- 
pended. 
"Mixed Treatment."-This term designates a 
method by which mercury and a salt of iodin are 
administered at the same time in a single dose. 
A 6-ounce mixture containing from 1 to 3 grains of 
the biniodid and from 1/2 to 2 ounces of the 
potassium iodid may be advantageously given in 
teaspoonful doses after meals. One of the bitter 
tinctures may be added to produce a tonic effect. 
The corrosive sublimate may be substituted in 
equal amount for the biniodid. 
The treatment of syphilitic lesions as they are 
presented in the several organs of the body: 
Syphilis of the skin yields to systematic treat- 
ment, but at times local treatment is of value. 
The erythematous and papular syphiloderms may 
be sponged with warm boric solution and anointed 
with an unguent having vaselin or cold cream for 
a basis, with from 5 to 20 grains of calomel or 
white precipitate to the ounce; or the following 
may be used: 
reversed to its former position, until the saline 
solution is running in a slow even stream from the 
needle. The desired site of puncture is selected 
on the arm or at the elbow, and the needle is 
gently pushed or thrust through the skin into the 
vein. Meanwhile the saline solution is continu- 
ously running from it. The needle is held at about 
an angle of 10 to 15 degrees to the skin surface, 
depending on the prominence and caliber of the 
vein. Care must be exercised not to push the 
needle through both walls of the vein. This can 
be avoided by not introducing too long a surface 
of the needle into the tissues. 
The patient's arm having been carefully cleansed, 
a ligature in the form of an ordinary soft rubber 
catheter or tubing is tied around the middle of the 
arm, above the selected site of puncture, and the 
patient is requested to tighten the fist so as to 
make the superficial veins more prominent. Some 
prefer to expose the vein in all cases. 
I). Mercuric chlorid, gr. iv 
Alcohol, 
Tincture of benzoin, 
Tincture of tolu, 
Glycerin, 
each, 5 j 
For the papular and scaling lesions nothing is 
better than mercurial ointment in full or reduced 
Rose-water, enough to make o iv. SYPHILIS 
SYRINGOMYELIA 
strength. Condylomata should be washed with 
deodorizing solutions of chlorinated soda or boric 
acid, after which they are to be dusted with equal 
parts of calomel and starch or with boric acid. 
Pustular lesions, especially over the face, require 
careful attention. Washing with hot boric solu- 
tion, followed by touching with a solution of corro- 
sive sublimate, 1 or 2 grains to the ounce of ben- 
zoin, should be followed by dusting with calomel, 
europhen, or boric acid. 
' Early syphilitic alopecia should be treated by 
shampooing with tincture of green soap 3 or 4 
times a week, followed by an unguent of white 
precipitate or calomel, 5 grains to the ounce of 
vaselin, or 1 dram of precipitated sulphur and 1 
grain of cinnabar to the ounce. 
Mucous patches should be touched daily with a 
silver nitrate solution, or with the solid stick. 
This should be done by the physician. For indi- 
vidual use, a lotion or gargle may be employed, 
such as 1 dram of potassium chlorate and 1/2 
ounce each of honey and tincture of myrrh to 6 
ounces of distilled water, diluted as required. 
When the palate is involved, medication should be 
prompt, both internal and local, and should be 
pushed to the largest tolerated doses. 
In cases of ozena a vapor from the following 
solution should be snuffed through the nostrsil: 
1$. Phenol, 3 j 
Tincture of iodin, 3 iv 
Ammonia water, 3 ij 
Cologne water, 3 iv. 
Pharyngeal lesions may be treated with medi- 
cated sprays, caustics, the galvanocautery, or the 
knife. 
The nails, when involved, should be bathed in 
warm borated water, followed by a weak mercurial 
salve or dusting-powder. 
Syphilis of the bones and periosteum calls, in 
general, for the iodid of potassium internally, with 
mercurial unguents or plaster over accessible nodes 
or tumors. Any sequestrum should be removed 
when completely separated. 
In all cases of visceral syphilis there is urgent 
need of systematic tonics, together with anti- 
syphilitic treatment. 
Lesions of the rectum and anus call for the 
iodids in large doses. 
Strictures should be dilated by rubber bougies; 
and when the result of such treatment is only 
temporary, surgical interference is indicated. 
WThen the epididymis or body of the testicle is 
involved, the iodid internally and abstention from 
sexual intercourse usually give good results. 
Lesions of the nervous system require the largest 
tolerated doses of the iodids, with inunctions of 
mercury at the same time. Tonics, a highly 
nutritious diet, and daily sponging with hot water 
are valuable. 
For treatment of the eye and ear, the reader is 
referred to the special articles on diseases of these 
organs. See Ear (Diseases), Iritis, Retinitis, etc. 
The special treatment of the syphilitic pregnant 
woman is by mercurial inunctions, together with 
the mixed treatment. When the syphilitic 
infant is at the breast, the treatment of the mother 
is not to be neglected. Only upon very strong 
evidence should direct treatment of a syphilitic 
infant be begun, since even after the birth of 
intensely syphilitic fetuses and a series of abortions 
there are brought into the world children who 
never exhibit signs of the disease even when both 
parents have been infected. The child should 
always be nourished by its mother, and should 
never be allowed to take the breast of a healthy 
wet-nurse. When symptoms are unmistakably 
present, the child may be given calomel, 1/20 to 
1/2 grain 3 times a day, together with tonics; or 
the protoiodid in doses of 1/10 to 1/4 grain; or 
corrosive sublimate, to grain. lodid of 
potassium may be given cautiously, from 1/4 to 5 
grains. Mercurial inunctions may be used in the 
earliest period of life. The ointment should be 
combined with 2 or more parts of pure white vase- 
lin, and increasing quantities should be used until 
20 to 30 grains are rubbed in daily. 
The acquired syphilis of infancy is chiefly 
remarkable for its display of moist and secreting 
lesions and for its failure to relapse in cycles when 
the disease is duly recognized and properly cared 
for. But in unrecognized or neglected acquired 
syphilis of infancy the results may be as mutilating 
and as disfiguring as in the worst phases of acquired 
disease of later years. 
SYRINGOMYELIA.-The morbid condition 
caused by the presence of an adventitious cavity in 
the spinal cord or by dilatation of the central canal. 
Pathologic Anatomy.-The cavities are formed 
partly by defective closure of the central spinal canal 
and partly by the breaking down of the residual 
embryonal tissue. The cavity of a syringomyelia 
is usually in the posterior part of the cord, extend- 
ing toward the posterior cornua. It may prevail 
throughout the entire extent of the cord, but in 
most cases involves only the cervical or dorsal 
regions or more limited areas. 
The essential symptoms are loss of sensibility, 
chiefly to pain and to temperature; and, to a less 
degree, loss of simple tactile sense; also muscular 
atrophy, the latter progressive in development. 
The sensory symptoms are the earlier and the 
more constant. There may not only be a loss of 
thermal sense, but it may be reversed, in that heat 
is felt as cold, and vice versa. So, also, subjective 
sensations are felt, including heat and cold, or in 
their absence pain, which may be neuralgic in 
character. The involvement of all forms of 
sensibility probably takes place when the postero- 
internal columns are extensively involved. The 
muscular atrophy is the result of injury to the 
motor cells of the anterior cornua in the compres- 
sion to which they are subjected in the dilatation. 
There is also muscular weakness, involving the 
trunk muscles, from which lateral curvature 
sometimes results. 
The reflexes may or may not be increased, and 
myotatic irritability may in rare cases be lost, 
while tremor of the limbs has been noted in some 
cases. Trophic symptoms are not rare in the parts 
affected by sensory loss. The skin may be glossy 
and thin, or thick and horny, while there may be SYRINGOMYELIA 
SYRUPS 
eczema, herpes, bullae, even ulceration and gan- 
grene. The nails may become fissured and drop off. 
Vasomotor disturbances are more common, includ- 
ing coldness, lividity, or redness with swelling and 
heat. There may be sweating, or its absence, brittle- 
eness of bone, and joint changes like those of tabes. 
The area of the cranial nerves may be invaded 
when there is involvement of the medulla and pons. 
The phenomena include paralysis of one vocal cord 
and of the tongue and face, difficulty in swallowing 
and in breathing, and embarrassed heart action. 
The eyes may be disordered; the pupils unequal, 
and smaller on the side where greatest severity of 
symptoms exists, but the other special senses 
escape, and the sphincters are unaffected. 
Diagnosis.-This is based upon the sensory 
symptoms, and of these, thermoanesthesia and 
analgesia, rather than tactile sensibility, together 
with muscular atrophy succeeding after some 
interval. Cervical pachymeningitis runs a more 
rapid course; the anesthesia includes all varieties 
of sensation, and corresponds more nearly in its 
distribution to that of the muscular atrophy; pain 
is more conspicuous, and the reaction of degenera- 
tion is commonly present in the wasting muscles. 
The symptoms of syringomyelia are sometimes 
simulated by the anesthesia and wasting of anes- 
thetic leprosy; but in the latter disease the trophic 
changes are more marked, the phalanges often 
drop off, while the sensory symptoms include all 
varieties of sensation. 
Progressive muscular atrophy differs in the ab- 
sence of altered sensation. A spinal tumor in the 
same situation as a syringomyelia furnishes almost 
identical symptoms, and may have an identical 
origin if it starts from the neuroglia; but the symp- 
toms are more rapid in their development (Tyson). 
Prognosis.-This is ultimately fatal, although 
the course is slow, extending over a period of from 
15 to 20 years. Toward the end the course is more 
rapid, death resulting from exhaustion or from 
interference with the functions of the medulla. 
Treatment.-This consists of measures to combat 
such symptoms as cystitis, bed-sores, etc., and 
general tonic and alterative measures. 
SYRINGOMYELOCELE.-See Spina Bifida. 
SYRUPS.-Concentrated solutions of sugar in 
water or in aqueous liquids. They sometimes 
contain acetic acid, and occasionally alcohol; and 
are termed simple, medicated, or flavored, according 
as they are simple solutions of sugar in water alone, 
or contain soluble medicinal substances or flavor- 
ing ingredients. The sugar used should be very 
dry, and its official description corresponds with 
the granulated sugar of commerce. The perma- 
nence of these preparations depends chiefly on their 
possessing the proper relative proportions of sugar 
nd water. They are prepared either by solutiona 
with heat, by agitation without heat, by adding a 
medicated liquid to simple syrup, by digestion or 
maceration, or by cold percolation. They are 
best preserved by being poured while hot into pint 
bottles, which should be corked securely while full, 
and the tops dipped into melted sealing-wax. 
Fermented syrups are useless for dispensing pur- 
poses. There are 29 official syrups. TABACUM 
TALIPES 
T 
TABACUM.-See Tobacco. 
TABES DORSALIS.-See Locomotor Ataxia. 
TABES MESENTERICA (Tuberculosis of the 
Peritoneum.)-See Peritonitis; Scrofula; 
Tuberculosis. 
TACHYCARDIA.-Abnormal paroxysmal or per- 
sistent rapidity of cardiac action. The pulse may 
attain a speed of 200 a minute. It is a compara- 
tively rare affection, due to paralysis of the inhibi- 
tory nerve of the heart or to stimulation of the 
cardiac accelerator nerves. See Heart-disease 
(Functional). See Heart Examination, Pulse. 
TAKA-DIASTASE.-See Diastase. 
TALIPES (Club-foot).-Talipes is the technical 
name for club-foot, whether congenital or acquired. 
Congenital talipes presents varieties not so numer- 
ous' and less complicated than the acquired form, 
ciated with cavus. The terms, then, would be 
talipes equinovarus, talipes equinovalgus, talipes 
equinocavus. 
2. Talipes varus is an inversion of the foot, asso- 
ciated with rotation at the midtarsal joint. The 
degree of the deformity is determined by the 
amount of manual correction possible and there are 
recognized: first, easily corrected and maintained; 
second, corrected and maintained with difficulty; 
and third, incorrigible by the hands. Ana- 
tomically, the tissues on the inner side of the 
ankle and foot are shortened, and certain ten- 
dons, such as the anterior tibial and the flexor 
brevis pollicis, are displaced toward the inner 
and posterior aspect of the limb, while the struc- 
tures on the outer side are lengthened and the 
tendons likewise are more or less displaced. Bones, 
Talipes Equinus. 
Talipes Calca- 
neus. 
Talipes Cavus 
ob Arcuatus. 
Talipes Varus. 
Talipes Equino- 
varus. 
Talipes Calcaneo 
varus. 
which develops after the second year of life. The 
features of congenital talipes are so pronounced 
that one can differentiate this from the acquired 
form. Acquired talipes is easily recognized, and 
is marked by a loss of power in certain groups of 
muscles, although it must be admitted that a 
moderate grade of talipes, resulting from slight 
paralysis in early life, may assume the characteris- 
tics of a congenital form in later life. Such cases, 
however, are exceptional. The different varieties, 
then, are: (1) Talipes equinus; (2) talipes varus; 
(3) talipes calcaneus; (4) talipes valgus; 
(5) talipes cavus; (6) talipes planus. 
1. Talipes equinus may be described as 
extension of the foot, with spasm or shorten- 
ing of the tendo Achillis, and usually with a 
loss of power in the anterior tibial group. 
The patient stands on the tips of the toes, 
on the distal ends of the metatarsals with 
the toes hyperextended, on the ball of the 
foot with the heel slightly raised or on the 
heel and ball of the foot, but is unable to 
dorsiflex the foot beyond a right angle. 
It will thus be seen that there are four grades 
of equinus. Equinus is more frequently com- 
bined with varus, but it may be associated 
with valgus and cavus. Congenitally, it is 
more frequently associated with varus, and, as an 
acquired deformity, with valgus. It is also asso- 
ligaments, muscles, and fascia all participate in 
these changes. Varus is associated with equinus, 
usually as a congenital deformity; less frequently 
as an acquired deformity. Occasionally it occurs 
with cavus; very seldom with calcaneus. 
3. Talipes calcaneus is, as a rule, an acquired de- 
formity; exceptionally, it is congenital. The 
deformity is characterized by elongation of the 
tendo Achillis and of the muscles associated there- 
with, by shortening of the anterior tibial group of 
muscles, and by slight flexion of the toes. The 
Talipes Valgus. 
Talipes Calcaneo- 
valgus. 
Talipes Equino- 
valgus. 
os calcis becomes very prominent, and the patient 
literally walks on the heel. This bone lies verti- 
cally in place of horizontally, in the severer forms 
and is continuous with the vertical axis of the leg. 
Calcaneus is associated with valgus, frequently 
with varus, and not infrequently with cavus. TALIPES 
TALIPES 
4. Valgus is usually acquired, rarely congenital, 
and is a deformity of the foot in which eversion is 
a prominent feature. The outer border of the foot 
is raised, the foot is everted, the patient stands on 
the inner border of the foot, and, as in the other 
varieties of talipes, presents the different degrees. 
In an extreme form the patient would bear the 
weight on the internal malleolus. Valgus is the 
opposite of varus, and is combined with equinus 
and calcaneus: never with cavus. 
5. Cavus is an exaggeration of the normal trans- 
verse arch of the foot, and is the result of bony 
subluxation at the midtarsal joint and of contrac- 
tion of the plantar fascia. The typical cavus of 
third degree is seen in the foot of a Chinese lady. 
6. Planus is the opposite of cavus and is a relax- 
ation of the ligamentous, fascial and tendinous 
structures in the arch and sole of the foot. The 
arch sags and there is a flat-foot. It may be 
relaxed or rigid and is due to many different causes, 
among which are obesity, occupation, ill-fitting 
shoes, right-angled equinus, and weakened tissues 
in the foot. 
Etiology of Talipes.-The appearance of talipes 
equinovarus, dependent upon slight paralysis 
many years previously and not influenced by 
treatment, is so much like the congenital deformity 
that the points of distinction are well-nigh obliter- 
ated; hence the popularity of the theory that a 
congenital club-foot results from an intrauterine 
paralysis. The theory advanced many years ago 
by Essericht, of Copenhagen, is that the feet of the 
fetus occupy various positions during the course 
of intrauterine life, in order that the joint surfaces, 
the muscles, and especially the ligaments may be 
developed in accordance with the future usefulness 
of the feet; that when anything centric or excen- 
tric prevents the feet from assuming these posi- 
tions at the proper time, or holds them in any given 
position beyond the limit of time during which 
they should normally occupy such a position, 
talipes results. The variety of congenital talipes 
will depend upon the date of its production; the 
severity will be in direct ratio to the mechanic 
obstruction at work. 
The etiology of acquired talipes is less difficult, 
the more common form being the result of anterior 
poliomyelitis, although it must not be inferred that 
talipes is the necessary result of the paralysis; it is, 
rather, an accidental result. 
Of themselves, few cord-diseases produce talipes; 
but the resulting muscular contractions induce the 
deformity. The bilateral equinus in cases of com- 
pression myelitis is well known; yet the deformity 
rarely receives treatment. In cerebral hemor- 
rhage in infancy the gastrocnemius is often the 
seat of a contraction that, by its long persistence, 
ends in contracture of the tendo Achillis. 
Ostitis of the ankle occasionally includes an 
equinus, a varus, or an equinovarus. Rachitis 
may be mentioned as one of the causes, but in 
reality, when deformity occurs, it is believed to be 
due to weak ankle or "spurious valgus." Cicat- 
rices from lacerated wounds of the ankle may be 
mentioned as another cause. 
Spastic paralysis has for one of its manifesta- 
tions an equinovarus or an equinus, usually first 
noticed when the child begins to walk. There also 
exists a marked inward rotation of the limbs, and 
the deformity is readily recognized, being bilateral, 
symmetric, and easy of correction by manual force. 
Many of the milder forms of talipes can be 
attributed to sprains of the ankle. However 
slight the deformity, the pain and annoyance 
caused by use are often greater than when the 
deformity is more marked, and to this mild grade 
of the deformity Schaffer has given the name of 
"nondeforming club-foot." Rheumatism may 
be mentioned as an occasional cause of talipes 
valgus; indeed, it is not an uncommon cause of 
what is known as spasmodic pes planus. 
The symptoms and signs of talipes and of its 
varieties may be gathered from the foregoing, and 
little need be said beyond the description already 
given. There are really very few symptoms that 
belong to talipes. The signs are those of deform- 
ity, and are noted either as the patient stands or 
walks. Occasionally, in very young children, 
when the deformity is congenital, standing and 
walking are not necessary to bring out the 
signs. 
Diagnosis.-The recognition of the various 
forms of talipes is easy, and particularly is this so 
of the deformity in the second and third degrees*. 
It is only in the first degree that confusion may 
sometimes arise. Many infants in arms .present 
certain evanescent deformities of the feet that are 
regarded as club-foot. A child, for instance, when 
it begins to stand, bears the weight on the toes and 
balls of the feet a good deal; the heels are raised, 
and deformity apparently exists. In especially 
stout children, in whom the gastrocnemius is 
flaccid, and in whom the tendo Achillis is easily 
stretched, a calcaneus can be produced, and often 
is produced. When the tendo Achillis is distinctly 
short, or when the anterior tibials are short and 
there is a history of paralysis, a talipes equinus 
or a talipes calcaneus may easily be diagnosed. 
Deformity must also be differentiated from weak 
ankles-a very common condition in rachitic sub- 
jects or in children who are very stout. 
Prognosis.-Talipes is a deformity that can 
easily be corrected at almost any stage; in a young 
child the prognosis is exceedingly difficult. It 
may be said that under efficient treatment, long 
continued, the prognosis is good: that is, a useful 
foot-one free from deformity-with functions 
fully restored. 
Treatment.-The treatment of talipes is both 
mechanic and operative. The two must not be 
regarded as separate and distinct, but as supple- 
menting each other. The most efficient treatment 
is a combination of the two. 
Mechanic.-The particulars underlying mechan- 
ic treatment are, first, an appliance that will hold 
the heel and the front of the foot in position; and, 
second, a lever that will correct. This lever must 
extend up the calf or to the thigh; sometimes to 
the pelvis. 
The principal types of club-foot shoe are: 
1. The Knight club-foot shoe, which is a modi- 
fication of the old Scarpa shoe. This consists of a TALIPES 
TALIPES 
foot-plate the shape of the sole of the foot, made 
of metal-steel preferably-covered by leather; a 
heel-cup of steel, consisting of uprights passing 
from a point just below one malleolus to the other; 
and leather, thin saddle skirting, shaped to a model 
of a heel, riveted to these steel uprights. An 
instep strap is also required, and this may be con- 
tinuous with the heel-cup. The upright consists 
of a spring of steel passing from the outer side of 
the heel-cup and terminating at a calf band that is 
secured in place by a leather band. Half of the 
band is of steel. Where the spring is attached at 
the ankle there is a stop-joint, which holds the 
foot at a right angle with the leg and allows dorsi- 
flexion, but no extension. In many instances 
there are double uprights in place of single ones. 
In adjusting this club-foot shoe the foot-plate is 
first secured to the plate by means of the instep 
strap and a bandage around the toe; then the 
spring is pulled back so that the calf band will 
grasp the calf. In making use of it, one must 
change frequently-at least twice a day-manip- 
ulate the foot at the same time, and guard against 
excoriations. 
2. The Taylor club-foot shoe is practically the 
same as the Knight shoe in principle, except that 
the spring is on the inner side of the leg, and in 
place of a small calf band there is a lacing attached 
to a plate that passes along the inner side of the leg. 
3. The Schaffer club-foot shoe is intended for 
traction on the tendo Achillis and on the plantar 
fascia. 
The operative procedures are: Division of ten- 
dons and fascia; subcutaneous division of liga- 
ments, either subcutaneously or by open method; 
open section, after Phelps; removal of the head and 
neck of the astragalus; osteotomy through the 
neck of the astragalus; cuneiform osteotomy 
through the os calcis, practised by Bradford; re- 
moval of the astragalus, known as astragalectomy; 
and supramalleolar osteotomy. All these are 
cutting operations, but the one most frequently 
resorted to is correction by manual force, fre- 
quently supplemented by the Thomas wrench- 
practically a tarsoclasis. 
The order of operation should be as follows: (1) 
Division of the tendo Achillis and plantar fascia, 
supplemented by manual force for overcorrection; 
(2) division of the tendons, supplemented by 
subcutaneous division of the deltoid ligament, and, 
in addition, manual force and the Thomas wrench; 
(3) the open division of all obstructing soft tissue 
on inner side of foot (Phelps); (4) removal of head 
and neck of astragalus; (5) cuneiform osteotomy 
(Davies-Colley); (6) supramalleolar osteotomy. 
The details of these various operations are 
simple, and few instruments are required. 
Tenotomy, fasciotomy, syndesmotomy, and 
myotomy are performed with a small tenotome 
not any longer than a fascia knife. The sub- 
cutaneous tenotomy is better than the open 
method, because the operation is simplified, and 
need never be followed by sepsis. There is no 
special instruction needed for the site of operation. 
The most prominent portion of tendon, fascia, 
ligament, and muscle invite, so to speak, the 
insertion of the tenotome either directly down 
upon it or underneath it. 
For the open method of Phelps the usual prepara- 
tions for an aseptic operation are necessary. The 
foot and leg are rendered as nearly bloodless as 
possible by an Esmarch bandage, and then an 
incision is made through the skin, beginning at a 
point about 1 inch anterior to the internal malleo- 
lus and extending across the inner margin of the 
sole rather obliquely for a distance of about 11/2 
inches. While eversion is made with one hand the 
section is continued to greater depths, until all 
tissues that offer resistance are divided. With 
foot thus in overcorrection rubber tissue is stretched 
over the gaping wound, and a sterile dressing 
applied over this and around the foot and ankle. 
The plaster-of-Paris may be applied before or after 
removal of the Esmarch bandage. The hemor- 
rhage is seldom an annoying feature, and the blood 
becomes organized, filling in the gap with new 
tissue. 
The operations of astragalotomy and astragalec- 
tomy are made through an incision over the head 
of the astragalus, prolonged sufficiently to admit 
of removal of the head and neck after section with 
osteotome, or of the entire bone after section of the 
ligaments holding it in place. The wound is sewed 
up with or without drainage, as the operator may 
prefer. 
The cuneiform osteotomy of Davies-Colley is 
made through an incision over the cuboid and 
fifth metatarsal on the dorsal aspect. The wedge 
includes usually the cuboid and a portion of the 
distal end of the os calcis or the proximal end 
of the metatarsal. The smaller portion of the 
wedge encroaches on the middle and external 
cuneiform bones and the astragalus. 
The section of the tibia and fibula above the 
malleoli is made subcutaneously by an osteotome, 
and the point selected is about 2 inches above the 
malleoli. Manual force supplements the section, 
and the foot is put up in eversion. 
All of these operative procedures are of little 
avail if the deformity is not overcorrected at once, 
and if the good position secured is not maintained 
by a dressing that does not yield. Plaster-of- 
Paris is to be preferred. One should not be con- 
tent with a single plaster-of-Paris dressing, but 
should renew this once a fortnight, getting the 
foot into better position at every dressing. 
After a few weeks in plaster the foot should be 
fitted with one of the club-foot shoes described 
and over this a shoe should be worn. The anatomy 
of the talipes foot must never be lost sight of, 
and the apparatus should be worn until nor- 
mality is reestablished. 
The mechanic treatment of flat-foot includes 
the construction of a boot or a shoe so that the 
inner border of the foot will be raised and the 
weight of the body thrown nearer to the normal 
vertical axis of the leg with the foot. 
This may be accomplished in two ways: (1) By 
building the boot on a last with a high arch-known 
as a Spanish last-and inserting an insole the inner 
border of which shall be from 1/8 to 3/8 inch 
thicker than the outer border, especially at the TAMPON 
TANNIC ACID 
heel and the ball of the shoe. (2) Fill in the 
shank with leather along the inner side the same 
height as the heel, and make the inner border of the 
sole and this elongated heel from 1/8 to 3/8 inch 
thicker than the outer border (Thomas). The 
effect of this is to remove the natural spring of the 
shank of the shoe and to throw the weight of the 
body over toward the middle and outer side of the 
foot. In the more severe forms of pes planus, 
associated with much bony deformity and spasm, 
correction of the deformity by manual force, under 
an anesthetic, and retention in plaster-of-Paris for 
two weeks will render the foot amenable to a 
steel shank worn within the shoe. The shank that 
gives most relief is known as the Whitman spring. 
The best fit is secured over an iron model taken 
from a cast of the foot in the corrected position. 
Cutting operations involving removal of bone 
are seldom called for, in view of the relief afforded 
by the milder operative procedures. 
In many cases it is advisable, and even necessary, 
to correct the deformity by manual force, under 
an anesthetic, and then allow the foot to remain 
in plaster-of-Paris some weeks before applying 
a sole-plate. The thorough and persistent use 
of exercise after the correction of the deformity 
is essential to the ultimate cure of the case and 
recovery may be aided by strapping with adhesive 
plaster to prevent external rotation of the os 
calcis and assist in supporting the arch. 
When flat-foot is of congenital origin, it is 
sometimes necessary to refresh the astragalo- 
scaphoid articulation, and to nail the bones together 
in a corrected position. In general, however, 
the operative treatment of flat-foot is rarely 
necessary. 
TAMPON.-Tampons are used principally for 
the purpose of applying pressure-as in uterine 
displacements and in vaginal and uterine hemor- 
rhages-and for depleting in pelvic and uterine 
inflammatory conditions. When depletion is 
desired, the tampon should be made of fine lamb's 
wool saturated with glycerin, or 10 percent 
solution of ichthyol in glycerin. The well-known 
hygroscopic action of the glycerin acts most 
favorably in cases of chronic congestion from 
laceration of the cervix, subinvolution, and 
pelvic inflammation. Tampons used for this 
purpose are removed at the end of 24 hours, after 
which a hot vaginal douche is given. They may 
be introduced at intervals of from 2 to 5 days. 
As a means of effecting continued pressure, 
tampons are occasionally useful in backward 
displacements of the uterus complicated by slight 
adhesions. Lamb's wool should here be used, and 
the tampon should be placed well back of the 
cervix in the posterior vaginal vault. It should be 
renewed daily. 
For the purpose of controlling vaginal and 
uterine hemorrhages nothing is superior to the 
tampon. The tampon in these cases should be of 
iodoform or sterile gauze. It is removed usually 
at the end of 48 hours. 
TANNALBIN.-A light brown powder recom- 
mended as an excellent intestinal astringent in 
chronic and subacute intestinal catarrh. Dose 
for adults, 1/2 to 1 1/2 drams; for children, 5 to 15 
grains. Tannalbin is a compound of tannin and 
albumin, and may be prepared as follows: To 10 
parts of a -10 percent solution of albumin 6.5 
parts of a 10 percent solution of tannin are added; 
the precipitate formed is collected on a strainer, 
washed, pressed, and dried at 30° C. The resulting 
mass is then triturated and forced through a fine 
sieve, and finally spread out in thin layers and 
dried for 6 hours at 120° C. This compound is 
only decomposed by the alkaline secretions of 
the intestines. 
TANNIC ACID (Tannin).-Tannic acid is a 
glucosid obtained from many vegetable astringents. 
The official tannic acid of the U. S. P. and B. P. 
is made from galls, and is distinguished from 
that occurring in leaves, barks, etc., by the name 
of gallotannic acid, while the others take the name 
of the source from which they are derived, as 
quercitannic acid, from oak bark. Tannic acid 
is solid, uncrystallizable, white or slightly yellow- 
ish, inodorous, without bitterness, very soluble in 
water, less soluble in alcohol and ether, especially 
when anhydrous, insoluble in the fixed and 
votatile oils. It is also very soluble in glycerin, 
and almost insoluble in absolute ether, chloroform, 
benzol, and benzine. It is incompatible with 
alkaloids, gelatin, albumin, and solutions of tartrate 
of antimony and potassium, and with ferric salts, 
with which it forms a black precipitate (the old- 
fashioned ink). It does not react with the salts 
of the ferrous oxid. If it is rubbed with the 
chlorate of potassium, the mixture explodes with 
great violence; hence these drugs should never 
be ordered in powder together, and if they are 
prescribed in the same solution, they should be 
dissolved separately. From tannic acid is pre- 
pared styptic collodion (containing 20 percent 
of tannic acid in the diluted collodion), troches of 
tannic acid (containing each 1 grain of tannin), 
and the ointment of tannic acid (containing 10 
percent). See Quercus. 
The effect of tannic acid resembles more closely 
that of alum than that of any other mineral 
astringent. It is more irritating, however, than 
the agent last named. This effect can be reduced 
in a measure by combination with borax and a 
small proportion of phenol. A paste prepared 
by mixing tannic acid two-thirds and gallic acid 
one-third is thought by some practitioners to 
be superior as a hemostatic powder to one in which 
only tannic acid enters. It enters in combina- 
tion with gun-cotton and ether, and in this form 
is known as styptic collodion. 
A combination of the effects of tannic acid and 
carbolic acid is obtained as follows: to a half pint 
of water add 1 dram of tannic acid and 2 grains of 
phenol; filter throughly, with care. Glycerite of 
tannic acid is useful in the proportions of glycerin 5 
parts and tannc acid 1 part. A tannated cotton is 
prepared by steeping absorbent cotton in a solu- 
tion of tannic acid. 
Tannic acid is of special value on mucous mem- 
branes and on abraded or superficially ulcerated 
skin surfaces. It is noted that many of its indica- 
tions are found in localities where sound integu- TANNIGEN 
ment joins a mucous- or ichor-yielding lesion, as 
at the nostril, anus, or vulva, and at the margins 
of ulcers, fissures, etc. 
TANNIGEN.-An acetic ester of tannic acid. 
Dose, 3 to 8 grains, up to 2 drams daily. A yel- 
lowish-gray powder used in chronic diarrhea as an 
intestinal astringent. 
TANNISMUTH.-Bismuth bitannate. It is 
claimed to be efficient in chronic intestinal ca- 
tarrh. Dose, 5 to 10 grains. 
TANNOFORM.-A compound of tannic acid and 
formaldehyd. It is a powerful intestinal antiseptic 
and astringent. Dose, 4 to 8 grains. It is used 
locally in 10 percent ointment or dusting-powder 
with 2 to 4 parts of starch. 
TANNOPIN (Tannon).-A condensation prod- 
uct of tannin with hexamethylenamin. It has 
the same action as its two components, into which 
it is gradually decomposed in the intestines. It is 
recommended in intestinal catarrh, in tuberculous 
enteritis, and other intestinal disorders. Dose, 
15 grams. 
TAPE-WORMS.-See Worms (Tape). 
TAPOTEMENT.-See Massage. 
TAR.-See Pitch. 
TARAXACUM (Dandelion).-The root of T. 
officinale. Its properties are due to a bitter ex- 
tractive principle; it is tonic, diuretic, and also 
aperient. It is of reputed use in dyspepsia. Dose, 
1 to 8 drams. T., Ext. Dose, 5 to 30 grains. T., 
Flext. Dose, 1 to 8 drams. 
TARTAR (Argol).-A hard mineral deposited 
on the inside of wine-casks as a whitish or reddish 
crystalline crust, the impure supertartrate of 
potassium. Tartar is also the name applied to a 
hard incrustation on the teeth, consisting of min- 
eral and organic matter. T., Cream of, purified 
argol or acid potassium tartrate. T., Emetic, 
the tartrate of antimony and potassium. See 
Antimony. 
TARTARIC ACID.-H2C4H4O8. A dibasic, 
organic acid, chiefly employed in refrigerant drinks 
and in baking-powders; 20 grains neutralize 27 of 
potassium bicarbonate, 22 of sodium bicarbon- 
ate, and 15 1/2 of ammonium carbonate. Dose, 
5 to 20 grains. It is widely distributed in the vege- 
table world, and occurs principally in the juice of 
the grape, from which it deposits, after fermenta- 
tion, in the form of acid potassium tartrate (argol). 
It results on oxidizing saccharic acid and milk- 
sugar with HN03. It crystallizes in large mono- 
clinic prisms, which dissolve readily in water and in 
alcohol, but not in ether. It melts at 167°-170° F. 
Its salts are the tartrates. See Antimony, Potas- 
sium, Tartar. 
TASTE, DISORDERS.-Taste is the sense by 
which savors are perceived and discriminated. The 
glossopharyngeal nerve and the lingual branch of 
the fifth pair are the nerves mainly connected 
with this sense, of which the tongue is the chief 
organ. The lips, the insides of the cheeks, the 
palate, and the pharynx also receive impressions 
from sapid substances. 
The chief sensations of taste are called sweet, 
sour, salt, bitter, and metallic. Flavor usually 
blends with the gustatory sense, but it is due to the 
sensation of smell reaching the olfactory mucous 
membrane through the posterior nares. If the 
posterior nares are closed, so that no air passes up 
through them, the sense of flavor is lost and only 
that of taste remains. It is necessary, therefore, 
to distinguish between the senses of smell and 
taste, and, as well, to determine how far sensations 
that are in themselves normal are responsible for 
alternation of the appreciation of the sense of 
taste: i. e., how far the sense of taste is increased or 
diminished in its enjoyment of or disgust at some 
article, the sensation itself being normal. 
Taste may be impaired or lost from a variety of 
causes: (1) from morbid conditions of the mucous 
membrane of the tongue and palate, as in chronic 
gastritis or rhinitis; (2) from lesions of the nerves 
concerned in the conduction of sensory impression; 
(3) from certain cerebral conditions. 
The first variety of causes is most common, and 
impairs, rather than destroys, the sense of taste. 
The parts of the mouth capable of receiving taste 
impressions are the tongue, the palate, and the 
palatine arches. A dry tongue or a thick coating 
dulls the sense of taste. 
The fifth nerve is the one usually concerned in 
disorders of taste. It is more likely that this 
nerve is concerned in taste impressions of the pos- 
terior portions of the tongue and soft palate than 
the glossopharyngeal nerve. 
In caries of the middle ear loss of taste for both 
the back and front of the tongue usually is noted. 
In general hemianesthesia and in hysteria loss of 
taste on one or both sides of the tongue and mouth 
is likely. Gustatory hyperesthesia occurs in 
myxedema and in mental and epileptic disorders, 
and is sometimes of central origin. 
Tests.-Various substances may be placed on 
the protruded tongue, the eyes being closed. The 
quantity of the substance should be small, and 
taste should be perceived before the tongue is 
withdrawn into the mouth. The following are 
used: for bitter, quinin; for sweet, honey; for sour, 
vinegar; for salt, common table salt; and for 
metal, a feeble electric current. 
Treatment.-This depends upon the etiology. 
Mercury or podophyllin as purgatives are to be 
used for a cankery taste unconnected with alco- 
holism, or half a glassful of pure, cold water may 
be taken half an hour before breakfast. Gray 
powder, 1/3 grain given 3 or 4 times daily, will 
usually remove from the mouth the disagreeable 
taste due to dypepsia, in chronic disease, or in 
early convalescence. Electricity may add to the 
function of taste when its loss or perversion is due 
to nerve-disease. 
TATTOOING.-The operation of marking the 
skin permanently by the introduction of foreign 
substances, such as carbon, India ink, and vermil- 
ion. It is a common practice among sailors, the 
color being introduced into the true skin by 
pricking it with needles. 
Tattooing as a therapeutic measure, to restore 
the natural colors in parts which are pigmented, 
is occasionally resorted to. For white, use baryta 
white; and for other colors, the earth colors (ochers 
-yellow, brown, red). To assist these, cinnabar 
TATTOOING TAXIS 
TEETH, EXTRACTION 
and ultramarine may be used. Mix the colors on 
a glass plate and impregnate the needles. Electrol- 
ysis, followed by tattooing, is useful in cases of 
vascular naevi. 
Tattooing of the cornea is an operation to dimin- 
ish the unpleasant appearance of leukoma of the 
cornea by tattooing the same so as to simulate the 
appearance of the normal pupil and iris. 
To Remove Tattoo Marks.-The method recom- 
mended by Variot is as follows: 
The skin is first covered with a concentrated 
solution of tannin, and retattooed with this in the 
parts to be cleared. Then an ordinary nitrate of 
silver crayon is rubbed over these parts, which 
become black by formation of tannate of silver in 
the superficial layer of the derma. Tannin pow- 
der is sprinkled on the surface several times a day 
for some days, to dry it. A dark crust forms, 
which loses color in 3 or 4 days, and in 2 weeks or 
so comes away, leaving a reddish scar, free of tattoo 
marks, and, in a few months, is scarcely noticeable. 
It is well to do the work in patches about the size 
of a silver dollar at a time. The person can thus 
go on with his usual occupation. 
TAXIS.-A reduction of a prolapsed structure, 
as a hernia or a prolapsed uterus, by methodic 
manipulation without instruments. See Hernia. 
TEA (Thea).-The leaves of Camellia theifera, a 
Chinese evergreen shrub. Tea contains an alka- 
loid (thein) and tannic acid, boheic acid, gallic 
acid, gluten, coloring-matter, etc. A decoction of 
the leaves is a popular astringent, restorative 
beverage, producing an exhilarating effect upon 
the nervous system. Used to excess, it powerfully 
affects the stability of the motor and vaso- 
motor nerves, the action of the heart, and the 
digestive function, producing flatulent dyspepsia, 
tremulousness of the limbs, pallor of the surface, 
irregular cardiac action and feeble impulse, hallu- 
cinations, nightmare, anorexia, headache, nausea 
and vomiting, obstinate neuralgia, especially of 
the supraorbital and occipital nerves; also consti- 
pation and a pain in the left side are not infrequent. 
The condition of chronic tea-poisoning is termed 
theinism or theism, and is very often seen among 
women of the lower class in cities, who do not in- 
dulge in alcoholic beverages, but freely accept 
the dominion of the "cup that cheers" and worse 
than inebriates. Tea contains much more tannin 
than coffee, and that used as a beverage by the 
poorer classes is little more than a decoction of 
tannin, and a fruitful source of dyspepsia and other 
forms of gastric disorder. The properties of tea 
are due to thein, CgH10N4O2, a substance identical 
with caffein and a mild cerebral stimulant. 
TEETH, ACHING.-See Toothache. 
TEETH, EXTRACTION.-When extracting any 
tooth carry the beaks of the instrument employed 
up under the free margin of the gums and alveo- 
lar process until you can close the forceps upon 
the middle third of the tooth, thus reducing in a 
large measure the possibility of breaking the 
crown off and leaving the root. The above acci- 
dent frequently results when one endeavors to 
extract by only grasping the tooth'at its neck. 
Position of Operator and Patient for the Extrac- 
tion of Teeth.-Have the patient seated in a solid 
chair, and his head tipped slightly back, on about 
a level with the operator's chest, who now takes 
his position on the right side, and passes left arm 
around the patient's head and places his fingers 
between the Ups in such a position as will best 
expose the teeth to be extracted and protect those 
not to be removed. 
This position is maintained when removing all 
the superior and inferior teeth from right lateral 
to left third molar with but slight shifting of palm 
and fingers to best support the face or mandible, 
and protect the lips from injury. Some operators 
will find it advisable to lower the patient and have 
his head carried slightly forward when extracting 
these inferior teeth. 
Take position to right and facing patient when 
removing all superior and inferior teeth from 
right cuspid to third molar. Protect lips and 
sustain face and body of mandible with palm and 
fingers of left hand. 
Order of Eruption of Permanent Teeth.-See 
Dentition. 
Forceps to be Employed in the Extraction of 
the Permanent Teeth.-Upper and lower incisors, 
No. 10 For Superior Third Molars. 
cuspids (canine), bicuspids and all roots can be 
removed by Dr. M. H. Cryer's universal forceps 
No. 150 and 151, manufactured by S. S. W. Co. 
For superior first and second molars, employ 
S. S. White's No. 88, right and left. 
For superior third molars S. S. White's No. 10. 
For inferior first, second, and third molars 
employ S. S. White's forceps No. 47. 
Detailed Description of the Application of the 
Forces to be Employed in the Extraction of all 
Permanent Teeth. Superior incisors.-First a 
slight rotary motion, and then carry the tooth 
bodily in a labial direction with slight traction. 
Superior cuspids {canines').-Carry the tooth in TEETH, EXTRACTION 
TEETH, EXTRACTION 
a labiolingual motion with positive careful 
traction. 
Superior first bicuspids.-Apply force cautiously 
in buccolingual direction, and positively no 
rotary motion employed for fear of fracture of the 
frail root ends. 
force to be applied should be slightly toward the 
cheek with positive traction that is directed a little 
backward. 
No. 151 Cryer's Universal Lower Incisor, Cuspid 
Bicuspid, and Root Forceps. 
Superior second bicuspid.-A slight buccal and 
rotary motion with gradual traction. • i> ■ 
Superior first and second molars.-Positive down- 
ward and slight buccal movement until the lingual 
root is gradually loosened, then careful traction 
without rotation. 
No. 88 R. For Superior First and Second Molars. 
To properly grasp some partially erupted infe- 
rior third molars, the bony alveolar process and soft 
tissues on buccal and lingual sides must be cut 
away before the beaks of the forceps can be prop- 
erly placed. 
No. 150 Cryer's Universal Upper Incisor, Cuspid 
Bicuspid, and Root Forceps. 
Superior third molars are easily extracted by the 
creation of traction buccally. 
Inferior incisors are removed by the application 
of labio-lingual motion. Great danger of root 
fracture with application of slightest rotary force. 
Inferior cuspids.-First a labiolingual force 
then a gradual rotary traction. 
No. 47 For Inferior first, second and third molars. 
Inferior first and second bicuspids.-A bucco- 
lingual force, then slight rotary motion. 
Inferior first and second molars.-A buccolingual 
and traction force without any rotary motion. 
Inferior third molars.-The most difficult one of 
the molars to extract; and the direction of the 
No. 88 L. For Superior First and Second Molars. 
Order of Eruption of Deciduous Teeth.-See 
Dentition. 
Deciduous teeth should be retained their full TEETH, EXTRACTION 
TEETH IN DIAGNOSIS 
term, for the known beneficial influence their pres- 
ence has upon the normal development of the jaws 
and face. 
When extracting the deciduous teeth, take same 
position as outlined as appropriate for the extrac- 
tion of the permanent ones. Forceps No. 250 and 
251 as designed by M. H. Cryer will be the only 
ones needed for the removal of all the deciduous 
teeth. 
Great care should be exercised when extracting 
deciduous teeth that the beaks of the forceps are 
not carried to a depth that might engage the 
oncoming teeth. 
In some pronounced cases the extracted tooth 
after proper sterilization has been replaced to 
control the hemorrhage. One precaution that 
should always be observed is that an operator 
should never dismiss a patient after the extrac- 
tion of a tooth until all pulsating hemorrhage 
has ceased. 
A Few Brief Statements in Reference to the 
General Question of Extraction of Teeth.-The 
use of an elevator for the extraction of any lower 
tooth should be condemned on the grounds that 
in their employment the mandible may be, and 
frequently has been, fractured. 
Care must be exercised in maintaining a positive 
grasp upon the extracted tooth until it is well out 
of the mouth, to prevent its slipping from the 
forceps into the patient's throat. 
When teeth are to be extracted from both 
arches, remove lower ones first, thus maintaining 
this field more free from blood. 
Cocain above a 1 percent solution should not 
be employed as a local anesthetic for the extrac- 
tion of teeth. 
Injections should not be made into an abscess 
area, but may be made about it. 
Chloroform is the most dangerous general anes- 
thetic that can be administered for the extraction of 
teeth, and nitrous oxid should always have the 
preference; when prolonged anesthesia is de- 
manded and continous nitrous oxid anesthesia 
cannot be maintained, ether should be employed 
and not chloroform. 
The superior and inferior second deciduous 
molars and cuspids (canines) should never be 
extracted before the child has reached the age 
when the permanent ones will soon be erupting, 
otherwise a positive irregularity of the permanent 
teeth will result. 
No permanent or deciduous tooth should be 
extracted if it can be made comfortable and 
useful. 
Teeth may be extracted during any stage of 
the formation of a dental alveolar abscess without 
danger to the patient. 
Never extract a patient's tooth without first 
informing him that you are about to do so; other- 
wise you betray your patient's confidence. 
TEETH IN DIAGNOSIS.-In hereditary syphilis 
the permanent teeth, especially the upper incisors, 
Illustrates the Jaws of a Child between six and seven 
years of age, showing the relations of the two sets of 
teeth.-{Harris.) 
Treatment of Post-operative Hemorrhage Fol- 
lowing the Extraction of Teeth.-To determine 
what socket is the seat of hemorrhage where a 
number of teeth have been extracted at one time, 
have the patient rinse out his mouth with a sterile 
solution, then immediately applying a previously 
prepared solid roll of cotton, about the size of the 
index finger over a number of the openings from 
which the teeth have been extracted, holding said 
pack under pressure from one to three minutes. 
Then remove and the deepest blood stain will be 
found above the socket where the excessive 
hemorrhage has been occurring. By this proced- 
ure you have the location and number of openings 
needing interference. 
For controlling this hemorrhage, employ a pel- 
let of cotton that will comfortably fill the opening 
to be packed. Saturate this with alcohol and then 
thoroughly incorporate it with powdered tannic 
acid (tannic acid causes the most insoluble clot to 
form in the presence of saliva). 
Now with curved dressing forceps force the 
medicated cotton pellet to the bottom of the 
socket and hold it in position until it has become 
well saturated with blood, and ceases to have a 
tendency to leave its position. 
Remove the pack in 24 to 48 hours and do not 
replace unless for the purpose of controlling a 
secondary hemorrhage. 
Mercurial Teeth. 
{Hutchinson.) 
Syphilitic Teeth. 
{Hutchinson.) 
are notched in a most peculiar manner. The cut- 
ting-edge, instead of being straight, with 2 or 3 
small serrations, is concave from side to side; 
the whole tooth is dwarfed, and, especially 
at the sides, is somewhat beveled off from 
above downward, so that it has a peg-shaped TEETHING 
TEMPERATURE 
appearance. This change, which was first de- 
scribed by Hutchinson, is characteristic; it very 
rarely, if ever, occurs under any other circum- 
stances, and it is caused by, and is proportionate 
to, the stomatitis of infancy. If this is severe 
at the time the dental papillae are developing, they 
are so much reduced in size and so altered in shape 
that it is almost impossible to recognize them as 
teeth. Mercurial teeth and malformed teeth after 
certain infantile exanthems, in which the enamel 
is defective transversely and is marked by horizon- 
tal darkened grooves and pits, are totally differ- 
ent, but it is not uncommon to find the two asso- 
ciated. In exceptional cases in which the stoma- 
titis has been late or prolonged, a similar change is 
visible in the lateral ones as well; but it is only the 
median teeth of the upper jaw that are definite and 
characteristic. 
TEETHING.-See Dentition. 
TEMPERAMENT.-A term vaguely applied to 
the predominance of one group or order of con- 
stitutional functions over others in an individual. 
The various divisions of temperament were based 
on the former doctrine of the four humors of the 
body-blood, lymph, bile, and atrabilious or black 
bile, the predominance of any one resulting re- 
spectively in a sanguine, lymphatic, bilious, or 
melancholic temperament. Although the doctrine 
of the temperaments has long since lost its signifi- 
cance, it is generally admitted that an individual 
may have a predisposition to types of mental action 
not improperly classed as nervous, phlegmatic, 
lymphatic, etc. 
Bilious temperament is that marked by a predom- 
inance of bile, persons of this type having sallow 
complexions, dark hair, sluggish circulations. 
They have great firmness and endurance. 
Lymphatic temperament is that characterized by 
fair complexion, light hair, flabby muscles, slight 
force of character, and slightly developed pas- 
sions. 
Nervous temperament is that characterized by 
great activity and sensitiveness of the nervous 
system. 
Sanguineous temperament is that characterized 
by fair or ruddy complexion, rapid pulse, a hope- 
ful disposition, and strong passions. 
TEMPERATURE.-Observations on the tem- 
perature of the body are valuable for diagnosis, 
because the temperature is easily altered when 
normal action of the nervous system is disturbed or 
in consequence of disease, or when toxic or in- 
fectious substances have been introduced into the 
body from without; because changes in the blood 
temperature occur to herald the onset of disease 
before even its presence is discernible or before 
even the slightest indisposition is present; because 
the courses of many diseases are accompanied by 
corresponding alterations of temperature, and 
because, in the numeric expression of the varia- 
tions, and the complex conditions of disease, the 
thermometer will detect earlier and judge more 
correctly the conditions of the patient's body than 
any other means. 
The temperature in health in the mouth of an 
adult is about 98.4° F. In the vagina and rectum 
it is 0.3° F. to 0.6° F. higher. In health there may 
be a difference of 20° F. between the temperature 
of exposed parts of the skin and the interior. 
Throughout the day the temperature varies. It is 
lowest between 2 and 6 a. m., gradually rising 
until its highest points are reached between 5 and 
8 p. M. This rise is usually slower in the middle of 
the day, the afternoon hours showing a more rapid 
elevation. These facts are of fundamental im- 
portance, since they affect the judgment of health 
and disease. Race and sex have no influence upon 
the range of temperature. Age does influence the 
range of daily temperature. In an infant just born 
the temperature is slightly higher. In the first 
weeks of life a higher temperature is maintained. 
The temperature is very easily influenced in 
children. In old age also the temperature is higher 
than in adult life, and a greater mobility of tem- 
perature is observed. Pregnancy has no appreci- 
able influence on temperature, although parturi- 
tion increases the temperature slightly. As a rule, 
the constancy of the bodily temperature in health 
is such that general conditions of life, occupation, 
etc., show but little influence over it. 
Local changes in temperature are brought about 
by local influences or by disease of a part. In a 
paralyzed limb the temperature may be lower or 
higher than in the other limb. In hemiplegia the 
paralyzed side is frequently higher in temperature. 
Neuralgia sometimes gives an increased tempera- 
ture in the part affected, and hysteria is liable to 
show a variety of temperature changes. 
In taking a temperature it is necessary: 
1. That no local influence, such as unusual 
exposure or the passage of cold air or of hot or 
cold fluids, shall affect the temperature of the part 
selected. 
2. That the bulb of the thermometer should be 
in most complete contact with surrounding parts, 
the column of mercury not being exposed. 
3. That ample time should be allowed for the 
mercury throughout the tube to attain an even 
temperature. 
4. That the thermometer should be read with 
the eye vertically over the point of the index. 
5. That the observation be cautiously repeated 
if the result is unexpected, and with a reliable 
instrument. See Thermometer. 
Depression of temperature is observed in hemor- 
rhage, starvation, wasting from chronic diseases, 
and diseases of the brain and spinal cord. In 
brain-disease, with the symptoms of melancholia, 
lowering of the general temperature and extreme 
coldness of the surface occur. In the collapse of 
typhoid fever, in acute peritonitis, and in poisoning 
by various substances, temperature is lowered. In 
cholera the axillary temperature may be 89.6° F., 
while the general temperature may reach 104° F. 
In alcoholic intoxication general temperature may 
be greatly lowered, particularly when the patient 
has been exposed to cold and wet. In chronic 
diseases of the respiratory tract, in chronic heart- 
or kidney-disease, and in chronic nephritis the 
temperature is somewhat lowered. 
Elevation of Temperature.-External cold after 
fatigue by exercise, in addition to the cooling of the TEMPERATURE 
TENDERNESS 
body from respiration, may be followed by a rigor, 
with rapid rise of temperature. No disease 
developing, the proper balance will soon be re- 
stored. The temperature may rise from such dis- 
turbance of the heat-regulating functions as the 
passage of a gall-stone or of a stone through the 
urethra. An injury may derange the nervous 
system and its heat regulation, causing the tem- 
perature to rise. Temperatures of from 110° to 
111° F. have been observed after injuries to the 
spinal cord (cervical portion). In tetanus tem- 
perature as high as 112.5° F. has been observed. 
In sunstroke or heat-stroke a similar point has 
been reached. There is sometimes a rise of tem- 
perature just previous to death. 
Hyperpyrexia has followed convalescence from 
acute rheumatism; and excessive rise in tempera- 
ture has caused death in hysteria, although a high 
temperature to which the pulse and respiration do 
not correspond is suspicious. 
In convalescence trifling external influences may 
cause a rise in temperature. 
Significance of Abnormal Temperatures.- 
Temperature is below normal at 97° F. (36.2° C.). 
Subnormal temperature is 97°-98° F. (36.2°- 
36.7° 0.). 
Normal temperature is 98.0°-99.5° F. (36.7°- 
37.5° C.). 
Temperatures Above Normal.-Subfebrile, 99.5°- 
100.5° F. (37.5°-38.5° C.). Moderate febrile, 
100.5°-102° F. (38.05°-38.88° 0.), for the morning; 
102.2°-103° F. (39°-39.44° 0.), for the evening. 
Febrile temperature of high degree, 102.5° F. (39.2° 
C.) and more in the morning; 105°-106° F. (40.6°- 
41.1° C.) in the evening. Hyperpyrexia, 105.8°- 
107.5° F. (41°-42° C.). 
A temperature below 93° F. (33.88° C.) or above 
108° F. (42.22° C.) is almost always fatal. As a 
single observation this is of value, and in a general 
way such observations are of value for diagnosis. 
When other symptoms exist, the knowledge of an 
altered temperature will alter the aspect of the case. 
Fatigue, and its effect on temperature, should, of 
course, be eliminated in a single observation of 
temperature. Systematic series of observations 
are of greater value. In types of pyrexia this 
method will indicate the mode of rising, whereby 
some disease may be distinguished. Thus, in 
pneumonia the temperature rises rapidly and con- 
tinuously to about 104° F. (40° 0.); in typhoid 
fever a gradual rise in each succeeding day of 
about 2° F. occurs, going down again each morning 
about 1° F., the maximum of about 105° F. being 
attained on the fifth day. At the height of a 
disease the temperature fluctuates about 103° F. 
(39.5° C.), the range varying in different diseases. 
Considerable remissions or intermissions may be 
observed in the decline of acute diseases, while in 
certain other chronic affections-such as syphilitic 
affections, tuberculous affections, in pernicious 
anemia or leukemia-the remissions become more 
marked as exhaustion of the patient increases. 
The intermittent type of pyrexia is shown in 
malarial diseases, chronic tubercular disease of the 
lungs, and pyemia. 
Crisis in the decline of a fever occurs when the 
temperature falls rapidly to or below the normal 
in from 12 to 26 hours, even in 6 to 8 hours. Lysis 
is the gradual decline of elevated temperature by a 
daily fluctuation. The former may be accompanied 
by collapse or acute delirium, neither of which 
is of unfavorable prognosis, and from which con- 
ditions patients rally well. Irregularity in tem- 
perature in a disease which usually runs a definite 
course indicates some complication. External 
causes easily influence temperature in convales- 
cence. See Chill, Cold, Fever, Heat-stroke. 
TENDERNESS.-The condition of abnormal 
sensitiveness to touch; soreness. It usually 
implies pain in varying degrees and of different 
kinds, elicited by pressure or by percussion, as 
distinguished from subjective sensation felt spon- 
taneously by the patient. It is a symptom of great 
importance, and merits close attention. It is 
often present when no complaint exists, while it is 
by no means an accompaniment of spontaneous 
pain. Its very absence is of consequence. Ex- 
aminations made to elucidate it require gentleness 
and discretion, and often an especial knowledge of 
anatomy and physiology. 
Tenderness in inflammation, especially when 
superficial, is of value in diagnosis. In neuralgic 
pain there is, on the whole, freedom from tender- 
ness. Pressure, indeed, often relieves it. So, 
when associated with a particular nerve, pressure 
may differentiate between inflammatory trouble 
and a merely functional disorder. Actual neuritis 
gives rise to tenderness. Pressure will relieve 
muscular rheumatism when not of inflammatory 
type. Malignant growths are usually accom- 
panied by pain and tenderness, while those of 
benign character are free from such symptoms. 
Destructive changes may be heralded by tenderness, 
as in diseases of the joints, in pressure from aneu- 
rysm or other tumor when there is, at the same 
time, spontaneous pain. Limited and obvious 
pain may indicate the presence of a foreign body. 
Localized tenderness on percussion is an important 
symptom in cerebral tumor. Tenderness is of 
value in diagnosis when there is no complaint by 
the patient, as in limited, obscure diseases of the 
abdomen, such as cancer, ulceration, or suppura- 
tion. It may also lead to undetected suppura- 
tion elsewhere. In children manifestations of 
pain during examinations will indicate the locality 
of morbid processes, and may lead to useful in- 
formation. General tenderness is a striking 
symptom of rickets. 
Acute erythema, erysipelas, peritonitis, gout, 
and spinal irritation are some of the affections in 
which tenderness is present. Other conditions 
are corns, bunions, chilblains, neuroma, superfi- 
cial and multiple neuritis, stumps after amputa- 
tion, boils, whitlows, felons, etc., and many 
affections of the eye and of the matrix of the nails. 
Treatment.-As a rule, treatment of the disease 
with which tenderness is associated will relieve the 
tenderness itself. All pressure is to be avoided, 
as from clothing and bedclothes. Cradles to lift 
off the coverings may be used. Hot and cold ap- 
plications, anodynes, and allied agents may be ap- 
plied locally. TENESMUS 
TESTICLE, ABNORMALITIES 
TENESMUS.-Rectal or vesical pain, with 
spasmodic contraction of the sphincter ani or 
sphincter vesicae. The painful desire to empty 
the bowels or bladder without the evacuation 
of feces or urine. 
Rectal tenesmus is a marked feature of dysen- 
tery. It may also be associated with other local 
diseases of the lower part of the rectum and anus, 
such as piles, fistula, or malignant diseases. 
Cystitis and pressure upon the bladder are causes 
of vesical tenesmus. 
Treatment.-Local causes must be removed or 
cured, when practicable. Moist applications of 
heat and cold, or small enemata containing lauda- 
num, or suppositories with morphin, extract of 
belladonna, or cocain hydrochlorid will often 
relieve the condition. See Cystitis, Dysentery, 
etc. 
TENIA.-A genus of parasitic worms of the 
class cestoda (tape-worms). They form ribbon- 
like stocks, composed chiefly of a row of con- 
secutive segments progressively increasing in size 
posteriorly (proglottides), and arising by strobila- 
tion from the knob-like head (scolex) which is pro- 
vided with organs of adhesion. Over 300 species 
are recognized, having for their hosts very widely 
separated animals, with correspondingly wide 
geographic distribution. See Worms (Tape-). 
TENIAFUGE.-See Anthelmintics. 
TENSION.-See Eye (Examination). 
TENT.-An instrument made of compressed 
sponge, laminaria, slippery elm, tupelo, or other 
material that increases in volume by the absorp- 
tion of water; it is used chiefly for dilating the cervix 
of the uterus. 
When lodged in the 
uterus, laminaria 
slowly expands the 
cervical canal, 
which in this way 
usually becomes 
accessible to the 
finger for diag- 
nostic purposes. 
The value of the 
agent in the main relates to the management of some 
of the consequences of abortion, or the postpartum 
retention of the products of conception. It is 
largely employed by some practitioners in facili- 
tating the application of local remedies to the 
endometrium. The use of the tent is always accom- 
panied by risk, and it should not be employed with- 
out extreme caution. It must not be introduced 
into the uterus when there is any evidence of 
pelvic inflammation. 
TEREBENE. C10H18.-A hydrocarbon ob- 
tained by the oxidation of oil of turpentine by 
means of sulphuric acid. It is soluble in alcohol 
and is recommended for winter cough as an ex- 
pectorant, and for inhalation in bronchitis. 
Dose, 5 to 15 minims on sugar or suspended in 
water. 
TEREBINTHINA.-See Turpentine. 
TERPENE.-One of a number of hydrocarbons 
analogous to turpentine oil. They have the 
formula C10Hlfl, or (C5Hs)n, and are contained in 
the volatile or ethereal oils obtained in the distilla- 
tion of various plants (chiefly Coniferce and Citrus 
species). The terpenes that have been thus isolated 
are very numerous. 
TERPIN HYDRATE. C10H18(OH)2.H2O.-Ob- 
tained by distilling oil of turpentine with an alkali. 
Useful in bronchial and pulmonary diseases to 
loosen and facilitate the expectoration of mucus. 
Dose, 1 to 5 grains. 
TERPINOL.-An oily substance formed by 
boiling terpin and terpin hydrate with aqueous 
mineral acids. It is a thick liquid, with a peculiar 
odor, boiling at 215-218 °C. Its uses are similar 
to those of terpin. Dose, 2 to 5 grains. 
TESTICLE, ABNORMALITES. Absence.-Com- 
plete absence of the testicle is sometimes seen, and 
such a subject presents the ordinary appearance 
of a eunuch. A well-developed seminal vesicle and 
vas deferens have been found with no trace of 
testicle, and vice versa. 
Supernumerary testicles have been described, 
but they are usually found to be fatty or fibrous 
tumors of the cord, old epiploceles, or encysted 
hydroceles. 
Malposition.-The abdomen, inguinal canals, or 
the perineum may be the retaining place of the 
testicle, or it may lodge in the subcutaneous tissue 
of the upper thigh or be in the inner and upper 
part of the thigh; or it may be so rotated in the 
scrotum that the epididymis is in front; or it may 
be there completely inverted. When there is 
malposition in the scrotum, it must have been 
caused by some abnormality in the development 
of the cord. The consequences of retention in the 
abdomen are arrest of development, sometimes 
fatty, fibrous or malignant degeneration, or, if 
otherwise normal, failure to secrete a fertilizing 
fluid. 
Retention in the Inguinal Canal.-Retention in 
the inguinal canal is often accompanied by in- 
guinal hernia, and when inflamed at puberty, 
causes great pain from the distention of surround- 
ing parts. In such cases peritonitis may cause the 
swelling to simulate a hernia. The testicle retained 
in the inguinal canal may be mistaken for a stran- 
gulated bubonocele or for a bubo. Retraction 
may be differentiated from retention by compari- 
son with the state of development of the correspond- 
ing side of the scrotum. A perineal or femoral 
position of the gland is not necessarily attended by 
any bad result. 
When the gland in the inguinal canal is attended 
by inconvenience, it may be placed in the scrotum 
by operation. Extirpation may be necessary if, 
from shortness of the cord, this is impossible. 
Trusses are not to be recommended for infants, 
even when malposition is complicated by inguinal 
hernia, as the hernia frequently subsides, and the 
truss will then interfere with descent of the testicle. 
When it has passed through the crural ring, the 
malposition cannot be remedied. If in the peri- 
neum or thigh, the testicle may be placed in the 
infantile scrotum by operation. Malpositions in 
the scrotum are important only from the stand- 
point of operations, as for hydrocele, etc. Arrest 
of development sometimes occurs even after the 
Slippery-elm Tent TESTICLE, HERNIA 
TESTICLE, INFLAMMATION 
testicle has passed into the scrotum, but with no 
serious consequences. 
Atrophy.-Rupture or ligation of the spermatic 
artery, and occasionally acute orchitis (especially 
that variety which is associated with mumps), are 
the chief causes, the testicle shrinking to a small 
nodule. Rupture or ligation of the vas deferens, 
chronic epididymitis, the pressure of ill-fitting 
trusses, and abuse may be followed by the same 
effect; but the wasting is seldom so extreme. 
Whether it is ever a result of varicocele is doubt- 
ful, though this is so often associated with a soft 
and flabby condition of the gland. 
Hypertrophy is said to occur as compensation in 
cases of unilateral retention. 
TESTICLE, HERNIA.-This condition is also 
known as " benign fungus of the testis," and may 
be superficial or deep. It is recognized as a fun- 
gus protrusion from the scrotum, the size of a pea, 
or even of a small egg, red or yellowish-red in 
color. In the deep form the tunica albuginea has 
been perforated, and seminal tubules form the 
greater part of the mass. It may occur after any 
form of suppurative orchitis. 
Treatment.-Well-adjusted pressure and appli- 
cations of silver nitrate or mercuric oxid may 
suffice. Freeing the margins of adhesions and 
suturing the over-stretched skin is usually very 
successful. If due to specific cause, antisyphilitic 
treatment is indicated. 
TESTICLE, INFLAMMATION (Orchitis; Epidid- 
ymitis).-Acute inflammation of the testicle is 
generally spoken of as orchitis or as epididymitis, 
according as the body or the epididymis is pri- 
marily or chiefly affected. 
Etiology.-Gonorrhea is the most frequent cause; 
but injury of the testicle, or irritation of the pros- 
tatic urethra, as from the tying-in of a catheter, 
or from the impaction of a calculus or frag- 
ment of a calculus, are not uncommon 
and of a dusky red color. When the inflammation 
is in the epididymis, the pain and swelling will 
be chiefly confined to the lower and back part of 
the testicle-the region of the epididymis-and 
fluid will often be detected in the tunica vaginalis. 
If the inflammation of the testicle occurs during an 
attack of gonorrhea, the discharge generally 
ceases or diminishes when the inflammation is at 
its height. The local signs are often accompanied 
by sharp febrile disturbance, elevated temperature, 
furred tongue, nausea, or even vomiting, and 
constipation. 
Treatment.-When the attack is acute, rest in 
bed, with the testicle supported on a pillow, is 
desirable. Cooling lotions, such as lead water 
and laudanum and a weak alcoholic solution 
of ammonium chlorid are time honored applica- 
tions. Hot moist compresses sometimes afford 
relief when cooling lotions fail. Recently hot 
saturated solution of Epsom salt has been highly 
recommended. Another much esteemed applica- 
tion is 25 percent guaiacol in olive oil or glycerin, 
painted over the affected half of the scrotum once or 
twice daily. Internally, a brisk purge should be 
given at the onset, followed by saline laxatives 
and small doses of antimony. If the pain is very 
severe, opium may be given. Urethral treatment 
must be stopped. 
If the effusion into the tunica vaginalis is ex- 
tensive, a few punctures may be made with a fine 
tenotomy knife, or an ordinary trocar and cannula 
may be introduced; and if the veins of the scrotum 
are distended, they may be pricked and encouraged 
to bleed, or leeches may be placed over the in- 
guinal canal; but, although it is largely practised 
by some surgeons, and apparently with impunity, 
puncture of the testis itself is not advisable. 
After the acute stage has subsided a properly fit- 
ting suspensory bandage should be worn. Martin's 
epididymitis bag is the most satisfactory American 
appliance. 
After the skin has been lightly anointed with 
vaselin, the suspensory bandage is lined with 
cotton and so adjusted as to raise the scrotum 
toward the abdomen. The degree of pressure can 
be regulated from time to time according to the 
amount of swelling and tenderness of the organ. 
An effort should always be made to secure 
resolution of the nodules which persist after the 
acute inflammation has entirely subsided. For 
this purpose the application of compound iodin 
ointment or oleate of mercury is useful, the latter 
applied .very sparingly so as not to produce 
great irritation of the integument. lodin in- 
ternally has been thought by some to favor reso- 
lution. Given in the form of syrup of hydriodic 
acid it will rarely, if ever, cause gastric irritation. 
Traumatic orchitis may be treated in the same 
way. When due to metastasis, warm fomenta- 
tions are better from the first; and if there is 
much infiltration of the scrotum, so that the con- 
dition of the circulation is doubtful, or if the 
patient is old and feeble, cold should not be used, 
for fear of gangrene. 
Chronic Inflammation.-This may begin as such 
or may be the relic of an acute attack. When 
Diagrammatic sections of (A) Orchitis, (B) Epididymitis, 
and (C) Hydrocele of the Tunica Vaginalis. Ho, Testis; N, 
Epididymis.-(Tillmanns.) 
causes. Orchitis sometimes occurs during an at- 
tack of mumps, and is then said to be due to metas- 
tasis. It has also been attributed to the use of 
strong injections for the cure of gonorrhea. In 
what manner inflammation of the testicle is in- 
duced by the irritation of the urethra is disputed. 
It is variously taught, however, that it is due to 
(1) inflammation spreading along the vas; (2) 
reflex irritation; and (3) metastasis. 
Symptoms.-In a well-marked case there is 
intense pain in the testicle, with a dragging or 
aching pain in the groin and along the course of 
the cord. The testicle is swollen, and is exquis- 
itely tender to the touch; the cord is slightly thick- 
ened; and the skin of the scrotum is edematous TESTICLE, INFLAMMATION 
confined to the body of the testis, it is nearly 
always due to syphilis; gout and malaria are 
exceptional causes. If the epididymis only is 
concerned, it is probably tubercular or urethral, 
and in the latter case it may be either the remains 
of an acute attack or chronic from the first. 
Syphilis occasionally affects the epididymis only 
(in the early secondary period), and not infre- 
quently both epididymis and testis. 
Symptoms.-The testicle appears enlarged, 
smooth, laterally compressed, egg-shaped, hard, 
heavy, and painful on pressure; the testicular 
sensation is not lost; the vas is but slightly 
thickened; the skin is nonadherent, and the epidid- 
ymis (except when the disease is limited to that 
part) is not distinguishable from the body of the 
organ. In chronic epididymitis an indurated, 
painful, and tender lump is felt in the situation of 
the globus minor or major. 
Treatment.-Mercury or potassium iodid should 
be given internally, and the enlarged organ may 
be strapped. Mercurial inunctions are also of 
value. 
Tubercular disease of the testicle, also known as 
strumous orchitis, or strumous sarcocele, is 
variously believed to depend upon the presence 
of the tubercle bacillus, or upon a chronic in- 
flammation in a strumous subject; and to begin 
either as a tubercular affection in the intertubular 
connective tissue or as a catarrhal inflammation 
in the interior of the tubules. 
Pathology.-Opportunities for examining the 
testicle in the early stages of the disease are not 
common, and there is uncertainty as to the origin 
and exact nature of the inflammation. 
Symptoms.-The disease usually begins very 
insidiously. The epididymis, especially the head, 
and, later, the body of the tesicle are found 
enlarged. The testicle is usually but slightly 
tender to the touch, and the testicular sensa- 
tion is not lost; a hydrocele may be present 
or part of the tunica vaginalis may be obliterated. 
Subsequently, the cord, especially the vas, be- 
comes thickened and the skin adherent; while 
still later the skin may give way and a fungus, 
composed of the infiltrated tubules, may protrude 
or a discharging sinus may be produced. When 
the testicle becomes adherent to the skin, soreness 
and pain will develop as the initial manifestations 
of the long-existing disorder. The seminal 
vesicles or prostate may now be felt enlarged 
on examining by the rectum, and bladder or 
urinary disorders may set in; while symptoms of 
tubercle in the lung, larynx, or other organs may 
supervene, and the patient may succumb to tuber- 
cular disease. At other times no constitutional 
signs manifest themselves, and the patient may 
completely recover. 
Diagnosis.-From syphilitic orchitis it may 
generally be distinguished by the enlargement 
of the epididymis, thickening of the cord, adhesion 
of the skin, enlargement of the seminal vesicles 
and concomitant signs of tubercle elsewhere. 
Treatment.-In the early stages, before the vas 
or seminal vesicles have become involved, 
some surgeons advise castration or resection of 
the epididymis for the purpose of preventing, 
if possible, general dissemination of the disease; 
and when both testicles are affected, even the re- 
moval of both. Others, however, rely on constitu- 
tional, hygienic and climatic treatment, and only 
advise the removal of the testicle should it become 
destroyed by the disease. If the seminal 
vesicles are found affected in the early stages, or if 
signs of tubercle are discovered in other parts, 
the testicle should, of course, on no account be 
excised. 
The constitutional treatment is that of tuber- 
culosis. 
The local treatment consists in suspension of the 
organ, avoidance of horseback riding or other 
violent exercise, and recumbency during an exac- 
erbation of the inflammation. Should the tuber- 
cle soften and suppuration occur, the abscess 
must be opened and the wound dressed with 
iodoform or other antiseptic. If intractable 
sinuses remain, they should be scraped with a 
Volkmann's spoon. If a fungus forms, it will 
frequently recede under rest in bed, cleanliness, 
and the application of a stimulating ointment 
or of iodoform. Should the testicle become 
completely disorganized, it had better be excised. 
Syphilitic Inflammation.-Subacute epidid- 
ymitis may occur in the early secondary stage, a 
painful irregular swelling making its appearance 
at the back of the testicle, involving the cord to a 
slight extent. It never possesses the severity of 
urethral epididymitis; the skin may be reddened, 
but is not edematous; and, like the other secon- 
dary symptoms with which it occurs, it subsides 
rapidly under mercury. 
True orchitis appears later, either during the 
intermediate period (when both glands are in- 
volved), or with the tertiary symptoms, when one 
gland is often attacked long before the other. As 
a rule, it does not affect the epididymis or the 
cord, and is very chronic in its progress; but often, 
in neglected cases, after the first testicle has been 
enlarged for some time, the second suddenly 
becomes actually inflamed, the skin grows hot 
and red, the tunica vaginalis distended, the 
epididymis affected as much as the testis, and the 
pain so severe that the patient is compelled to 
apply for relief. 
Symptoms.-The character of the swelling 
depends upon the distribution of the syphilitic 
exudation and upon the changes it undergoes. 
In some cases, especially the earlier ones, there is 
uniform enlargement of the whole gland, so that it 
remains ovoid, smooth, and even, and merely 
becomes heavy and intensely hard; in others 
the surface is nodular and uneven in con- 
sistence, dense indurated patches alternating 
with others that are soft and elastic. The exuda- 
tion, in other words, may be uniformly distributed 
throughout the whole of the fibrous tissue of the 
gland, or it may be aggregated either into one 
central gumma or into numerous scattered 
gummata of various sizes; and, according to the 
success of the treatment, it may be completely 
absorbed, merely leaving a slight depression, or 
may become organized into cicatricial bands, or 
TESTICLE, INFLAMMATION TESTICLE, PAIN 
TESTICLE, TUMORS 
may break down and undergo caseation and 
liquefaction. Occasionally, this ends in suppura- 
tion and hernia testis; more frequently, partial 
absorption takes place, and a hard, irregular mass 
is left, sometimes in the middle, sometimes at 
one side of the testis, composed of a caseous or 
even calcareous center, surrounded by an im- 
mense thickness of cicatricial tissue-a so-called 
chronic abscess. 
The size to which a testicle may attain under 
these conditions is enormous; usually, when, 
large, it is painless and is devoid of testicular 
sensation. Heat, redness, thickening of the cord, 
edema of the skin, and effusion into the tunica 
vaginalis are signs of acute inflammation, and 
are only present when the testicle is first at- 
tacked or when a fresh gumma suddenly develops. 
Cases of this kind have lasted for 10 years, with 
occasional subacute attacks compelling the patient 
to apply for relief, until at length the testicles 
were enormously enlarged, irregular in shape, 
hard, painless, and absolutely devoid of sensation. 
The diagnosis of syphilitic orchitis is rarely 
difficult; the only form that resembles it is that 
occurring in gout. The chief features are the 
essentially chronic character of the affection 
(varied from time to time by more acute attacks); 
the smooth, hard, heavy character of the swelling; 
the disappearance of the epididymis, which in 
many instances is so flattened out that it cannot 
be felt (occasionally, it is enlarged); the absence 
of pain (during the greater part of the time) and 
of testicular sensation; and the fact that both 
testes are involved, though usually not to an 
equal degree. 
Treatment.-In epididymitis and recent orchitis 
mercury may be given freely, with a view to 
causing speedy absorption; later, especially if the 
disease has relapsed, more benefit is derived from 
small doses of bichlorid of mercury, continued with 
occasional interruptions. lodid of potassium always 
causes a rapid diminution in size, but absorption 
of the syphilitic exudation is rarely complete; it 
progresses up to a certain point, continues as the 
dose is increased, and then comes to a standstill, 
leaving a dense mass, over which nothing appears 
to have any influence. The acute symptoms, 
however, are quickly relieved by it. Occasion- 
ally, other remedies are of service: mercury, for 
example, rubbed into the skin on the inner side of 
the thigh (it cannot be applied to the scrotum), 
strapping, or the removal of hydrocele fluid. If 
suppuration occurs, the abscess must be opened; 
and at length, if the testis becomes useless and is 
a constant source of pain and suffering, castration 
may be advisable. 
TESTICLE, PAIN.-Pain and retraction of the 
testicle are of frequent occurrence in disease of the 
kidneys and in affections involving branches of the 
lumbar plexus; further, after obliteration of the 
vas, sexual intercourse, or even sexual excitement, 
may be attended by severe pain and swelling of 
the gland; in addition to this, however, in certain 
persons the testicles are liable to attacks of intense 
neuralgia, coming on at regular intervals or excited 
by the most trivial irritant. Usually, one only is 
affected, but both may be; the gland may be ap- 
parently well nourished, or it may be small and 
flabby; it may be exceedingly irritable, resenting 
the slightest touch, or there may be nothing note- 
worthy about it. In many cases there is a history 
of injury, but it seldom stands cross-examination. 
Gout, malaria, anemia, and other constitutional 
ailments are sometimes present. Neuralgia of the 
testicle may occur in the most continent; and 
though in many there is a history of abuse, it is 
difficult to connect one condition directly with the 
other. Sexual hypochondriasis may be associated 
with it, and often the family history is decidedly 
neurotic. 
Treatment is very unsatisfactory. Any local or 
constitutional cause that can be detected must, of 
course, receive thorough consideration; a suspen- 
sory must be worn; lead or some other cooling 
lotion should be applied; and the thoughts and 
ideas directed into other channels. Cupping over 
the loins, massage bf the back, and the free (local) 
use of anodynes may be tried as well. If there is 
a large varicocele, operation may give relief, but 
castration is useless. 
TESTICLE, REMOVAL.-See Castration. 
TESTICLE, TUMORS. Hematocele.-See 
Hematocele. 
Hydrocele.-See Hydrocele. 
Dermoid and hydatid cysts are occasionally met 
with. The former may be recognized by their 
congenital origin, though often they do not attain 
much prominence until late in life, and their uneven 
consistence; but no certain diagnosis can be made 
without puncture. 
Cystic adenoma is more common. Like parotid 
glandular tumor, it is peculiar to the organ from 
which it springs, and only admits''of a somewhat 
vague comparison with other growths. It con- 
sists of cysts of all sizes, lined with cubic or 
flattened epithelium, filled with a clear brownish 
or greenish fluid, and developed from the semin- 
iferous tubules, the epithelium of which has either 
lost or has never acquired its distinctive characters. 
A variable amount of fibrous tissue exists between 
them, sometimes undergoing myxomatous de- 
generation, and occasionally mixed with cartilage. 
Intracystic growths may occur as well. Tumors 
of this kind may occur at any age, but they are 
rarely noticed before puberty. Growth^is slow 
and painless, the patient suffering no'inconven- 
ience other than that due to the weight. The 
vas is never affected, and secondary deposits do 
not occur, the cases in which this is said to have 
taken place having really been sarcomata, with^an 
accidental development of cysts. 
Fibroma and enchondroma of the testis are met 
with in young adult life, but they are both very 
rare. The chief clinical feature is the slow growth 
of a hard and heavy painless mass. ^The surface 
is usually smooth, but it may be nodular, suggest- 
ing the presence of cysts. Growths of this kind 
do not extend along the cord, invade other organs, 
or recur; but removal is always advisable. There 
is no means of distinguishing one from the other 
but by a section. 
Carcinoma of the testis is nearly always encepha- TESTICLE, TUMORS 
TESTICLE, TUMORS 
loid, though a few cases of scirrhus have been 
described. It is stated to be most common be- 
tween 20 and 40 years of age. The beginning is 
usually very insidious; the testis is enlarged, 
smooth, ovoid, and at first fairly firm; the cord is 
not thickened, nor are its components matted 
together, but it is fuller than the other, and the 
veins over the scrotum are distended. There is 
little or no pain or tenderness, and testicular 
sensation is soon lost. In a very few weeks there 
is a rapid increase in size; the tumor is softer, the 
surface uneven, the cord distinctly thickened, the 
shape becomes globular and the epididymis 
flattened out at the back. If left, it becomes so 
soft that it almost seems to contain fluid; the skin 
becomes adherent, the veins are more distended, 
the thickening extends higher up the cord, and, 
perhaps, if the patient is thin, an ill-defined sense 
of resistance can be made out by deep pressure 
at the back of the abdomen. The skin of the 
scrotum soon gives way, allowing a bleeding mass 
to protrude, the glands of the groin enlarge, 
secondary deposits make their appearance in other 
organs, and the patient sinks rapidly from 
exhaustion. 
Sarcoma of the testicle presents greater variety of 
appearance and character. It may be round- 
celled or spindle-celled, and the latter especially 
may become more or less converted into cartilage 
(without, however, losing one atom of its malig- 
nant sarcomatous character); sometimes there are 
only nodules here and there, sometimes branching 
outgrowths-due, perhaps, to the spreading of 
the disease inside the lymphatics-and occasion- 
ally so much that the original sarcomatous growth 
is hard to find. In addition both of these forms 
may be associated with cysts, due either to soften- 
ing and hemorrhages or to distention of the seminif- 
erous tubules, with proliferation of the epithelium 
lining them, and occasionally intracystic growths, 
so that they may present a close resemblance to 
some of the forms of cystic adenoma. Sarcoma 
may occur at any age, even before birth, though 
it is most common under 10 years and between 30 
and 40. The round-celled variety, unless the 
patient is a child, or unless both testicles are 
attacked at once, cannot be distinguished from 
encephaloid carcinoma; the progress is as rapid, 
and the glands of the lumbar and other regions are 
involved as soon; if possible, it is even more fatal. 
The other variety is much less uniform in rate of 
growth and consistence; it may, for example, be 
formed almost wholly of cartilage or of fibrous 
tissue; cysts are less common, and it does not 
appear to fungate so readily; but the ultimate 
results-the infiltration of the glands with growth 
of the same histologic character as the primary 
one, and the secondary deposits in the lungs and 
other organs-are equally certain. 
Teratomata.-These are congenital tumors con- 
taining embryonal tissue elements from the three 
blastodermic layers. Dermoid cysts also belong 
to this class. Many of these tumors are exceed- 
ingly malignant, especially those which contain 
tissue resembling chorioepithelium. 
Treatment.-Sarcoma, carcinoma, and the tera- 
tomata should be removed as soon as the diagnosis 
is made. The usual operation of castration is 
inadequate for the removal of malignant tumors 
of the testicle. Although it is impossible to reach 
the lymphatics which drain the testicle at their 
termination, they should nevertheless be divided 
as high up as possible. 
Following the method of Cumston and Rolfe an 
incision is made parallel to, and about three 
quarters of an inch above, Poupart's ligament, the 
inguinal canal laid open, the cord freed and 
lifted out. The iliac fossa is then entered by an 
opening made through the posterior wall of the 
canal. The vas is followed downward into the 
pelvis as far as possible, cut, and the stump 
touched with pure carbolic acid. The spermatic 
vessels are then traced upward as far as possible, 
ligated in two places and divided between the 
Ligatures. The cord is separated from its coverings 
from above downward to a point below the 
external ring. The testicle may be pushed up 
and removed with the cord unless it is very large, 
when a longitudinal incision down the scrotum is 
required for its removal. The prognosis is very 
unfavorable, but in all probability this is due in 
some measure to delay; there is evidence to show 
that if castration is performed in time, recurrence 
may not take place for many years. Even if the 
skin is involved and the cord thickened, the opera- 
tion is advisable in order to save the patient from 
the formation of a fungus, if only there is reasonable 
prospect of securing immediate unionof the wound. 
Diagnosis of Tumors of the Testes. Age.-A 
tumor that appears in infancy is probably hydro- 
cele; sarcoma and syphilitic and tubercular orchitis 
occur, but are very rare in comparison. 
Etiology.-A definite history of accident de- 
serves consideration, though it may merely have 
drawn attention to an already existing, but un- 
suspected, enlargement. Sarcoma as well as 
hematocele may follow injury. 
Rapidity of Growth.-Hematocele is an affair of 
minutes, or, at most, of hours; malignant disease, 
of a few weeks. Acute orchitis presents no 
difficulty in diagnosis; chronic inflammation, on 
the other hand, if only one side is involved, if 
there is no evidence of constitutional complaint, 
and if there are but little heat or pain and no 
redness, can often be diagnosed only by the results 
of treatment. Syphilitic orchitis, for example, 
may, so far as a single examination is concerned, be 
indistinguishable from incipient malignant disease. 
Duration.-If the tumor has lasted more than 6 
months without the doubt in diagnosis clearing up, 
it is not malignant. 
Consistence, whether solid or fluid. Hydrocele 
and hematocele are the only fluid tumors at all 
common, but there are many sources of fallacy. 
A hydrocele may conceal an enlargement of the 
testes (hydrosarcocele). Old hydroceles and 
hematocele may have walls of such thickness as to 
appear solid, and rapidly growing malignant 
tumors may be as soft and elastic as if they con- 
tained fluid. 
Translucency.-This distinguishes at once thin- 
walled hydroceles. TESTICLE, TUMORS 
TESTICULAR EXTRACT 
Number.-Hydrocele and sarcoma may occur 
on both sides, but when both testes are affected, 
the tumor is nearly always of inflammatory origin. 
Shape.-If the tumor retains the shape of the 
testis, it is probably either chronic inflammation or 
incipient malignant disease. Sarcoma and carci- 
noma (when more advanced), hematocele and en- 
cysted hydrocele, are all spheric; other tumors are 
very irregular. 
Pain and Sensitiveness.-Hematocele may be 
very painful at first; the others-except acute 
inflammation- are rarely attended by pain. In 
chronic orchitis, malignant disease, and hematocele 
testicular sensation soon disappears. 
The Condition of the Cord.-In chronic orchitis, 
hydrocele, and hematocele, the cord is not affected. 
In acute inflammation and incipient malignant 
disease it feels full because of the increased amount 
of blood. In acute epididymitis and advanced 
sarcoma and carcinoma it is thickened and all its 
component structures are welded together. The 
vas itself is enlarged in tubercular epididymitis. 
The skin is not adherent unless there is acute 
inflammation or advanced malignant disease 
(Moullin). 
The following table, from Keyes and Stewart, 
shows the main points in the diagnosis of chronic 
diseases of the testicle: 
Simple Chronic 
Epididymitis. 
Tuberculosis. 
Syphilis. 
Tumor. 
History 
Gonorrhea, stricture, or 
hypertrophy of pros- 
tate. 
Tuberculosis, family or 
personal. 
Syphilis inherited or 
acquired. 
Perhaps trauma. 
Frequency 
Uncommon 
Frequent 
Frequent 
Rare. 
Size 
Small between attacks... 
Does not reach any 
great size. 
Does not reach any 
great size. 
May reach any size. 
Tenderness 
Yes 
Yes 
No 
No. 
Shape 
Between attacks testis 
normal, epididymis 
nodular. 
Epididymis nodular 
Testis not involved 
unless acute or ancient. 
Testis evenly enlarged, 
slightly nodular, "clam 
shell" epididymis. 
Testis greatly enlarged, 
no characteristic in- 
volvement of epidid- 
ymis. 
Cord 
May be slightly thicken- 
ed. 
Enlarged and nodular... 
Free 
Free. 
■ ■ ■ - 
Seminal vesicles 
Usually distended 
Tuberculous 
Uninfluenced 
Uninfluenced. 
Prostate 
Posterior urethra in- 
flamed. 
Congested or tuber- 
culous. 
Uninfluenced 
Uninfluenced. 
Urine 
Cloudy 
Cloudy, may contain 
bacilli. 
Clear 
Clear. 
Hydrocele 
Unusual 
Often 
Nearly always 
Unusual. 
Onset 
Usually acute 
Usually chronic 
Chronic 
Chronic. 
Age 
Adult life 
Not often after 30 
Middle life 
Any age. 
Origin 
Epididymis 
Epididymis 
Testicle 
Testicle. 
Course 
Recurring acute attacks. 
Chronic 
Very chronic 
Usually rapid. 
Suppuration 
Unusual 
Common 
Rare 
None, but fungus com- 
mon in later stages. 
Atrophy of testis.... 
Rare, potency unim- 
paired. 
Rare, potency some- 
what impaired. 
Common, potency 
somewhat impaired. 
Never, potency unim- 
paired. 
Opposite testicle 
Often involved simul- 
taneously. 
Usually .involved sub- 
sequently. 
Free 
Free. 
TESTICULAR EXTRACT (Orchitic Extract).- 
This substance has been recommended as a general 
tonic for the aged, for subjects of impotence, or 
for a debilitated nervous system. It has been 
used in general adynamia, anemia, atonic gastro- 
intestinal affections, scurvy, malaria, epilepsy, 
cancer, nymphomania, perverted sexual habits, 
impotence, neurasthenia, hysteria, melancholia, 
diabetes, tuberculosis, hemiplegia, paralysis agi- 
tans, and locomotor ataxia. 
It is prepared in the following manner: The 
testicles of bulls, enveloped in their membranes, 
are washed in a 10 percent solution of sublimate, 
and again with sterilized water, are each divided 
into 5 or 6 parts, placed in aseptic glycerin (a pint 
to the pound of testicle), and allowed to macerate 
therein for 24 hours. An equal quantity of a 5 
percent solution of common salt in boiled water 
is then added, and the mixture is filtered and 
sterilized by being subjected to a pressure of 30 TESTIMONY, MEDICAL 
TETANUS 
atmospheres of carbonic acid gas. The dose is 
from 10 to 20 minims hypodermically, once daily 
or every other day, with strict aseptic precautions 
as to the syringe used and the site of injection; 
the latter should be washed with a 1:1000 subli- 
mate solution or with a 2 percent solution of 
carbolic acid. The extract seems to have little 
or no effect when given by the mouth, but is 
efficient when administered by the rectum. 
TESTIMONY, MEDICAL.-See Expert Testi- 
mony. 
TESTS.-See Urine (Examination), Blood 
(Examination), Sputum, Stomach-contents, 
Bacteriology, Pathologic Technic, Vision 
(Tests), Hearing (Tests), etc. 
TETANUS (Lock-jaw; Trismus).-An infectious 
disease, marked by tonic spasms of the voluntary 
muscles, with distinct exacerbations. The con- 
tractions may be confined to the muscles of the 
lower jaw (trismus) or to certain other groups of 
muscles, or they may involve the muscles of the 
whole body. Tetanus may occur at any age. It 
the frog is immune. It is said, however, that if 
the body temperature of the frog is increased it 
becomes susceptible. The bacillus of tetanus 
stains well with all the ordinary aqueous solutions 
of anilin dyes and by Gram's method. 
Symptoms.-At first the patient finds stiffness 
in the movement of the jaw; he experiences 
uneasiness in swallowing, and soon perceives that 
he has difficulty in separating his teeth for the 
admission of food. He begins, now, to feel pain 
behind the sternum, and this pain extends from 
the pit of the stomach toward the vertebral 
column. The muscles of the back and those 
of the back of the neck begin to be affected by 
spasms; then those of the abdomen, afterward 
those of the limbs, and lastly those of the face. 
The muscles become more and more rigid as the 
case proceeds. In the extreme period of the 
disorder all the muscles of voluntary motion are 
affected; among others, those of the face; the 
forehead and nose are drawn up; the eyes are 
distorted, fixed, and motionless; the cheeks are 
retracted, and the features undergo an extraor- 
dinary change. The spasms become universal, 
and a violent convulsion puts an end to the 
misery of the patient. 
Profuse sweating usually occurs during a par- 
oxysm. The temperature in some cases is normal 
throughout; in others there is marked pyrexia 
from the outset, the temperature reaching 105° or 
106° F. before death, and being 109° or 110° F., 
and even higher, soon after death. When'"death 
occurs, it is usually due to exhaustion, inanition; 
spasm of the diaphragm, or the muscles of respira- 
tion; spasm of larynx, with asphyxia; arrest of 
heart action from spasm or paralysis. 
Diagnosis.-The symptoms are so character- 
istic, with the addition of a history of a wound, 
that an error seems hardly probable. 
Tetany.-The spasms chiefly affect the ex- 
tremities, the muscles being free in the interval 
and trismus a late or very rare condition. 
Strychnin poisoning often closely resembles 
tetanus, but there is no beginning trismus and 
there is more rapid development of the symptoms. 
No history. 
Hydrophobia does not have trismus; but respir- 
atory spasm occurs, excited by attempts at swal- 
lowing, with increasing mental symptoms. 
Prognosis.-In the acute form the prognosis is 
very grave; in the chronic form it is favorable. 
Treatment.-The indications are to keep up the 
strength of the patient until the disease ceases; to 
remove, as far as practicable, all conditions be- 
lieved to have the power of creating the tetanic 
state; and to employ any sedative or special 
treatment from which it may be hoped to derive 
advantage. Perfect quiet is absolutely essential; 
the room should be darkened, and the patient 
kept, as nearly as may be, in perfect repose; 
remedies should be administered as gently as 
possible; everything harsh or violent should be 
avoided. If nourishment cannot be swallowed, 
it should be administered through the anus; it 
should be as plentiful as the nature of the case 
will admit; the supply of brandy and wine should 
Bacillus of Tetanus, Showing Spores.-{Frankel and. 
Pfeiffer.) 
is often epidemic among children. Males suffer 
oftener than females by about 4 to 1. 
Etiology.-Tetanus is caused by a specific 
bacillus-the tetanus bacillus, first discovered by 
Nicolaier, and first obtained in pure culture by 
Kitasato. It is present in surface soil and dust. 
This explains the fact that wounds which have 
been infected by dust or earth are so often followed 
by tetanus. 
This bacillus is long, slender, and swollen at one 
end in the shape of a " drumstick," in which a spore 
develops. The germ is generally isolated or in 
pairs, and is motile, but has no flagella. The ba- 
cillus of tetanus is anerobic. It is exceedingly 
resistant to the action of heat and to that of carbolic 
acid solution. It grows upon artificial culture 
mediums, such as gelatin, bouillon, and with 
gelatin containing glucose. 
Men, horses, mice, rabbits, and guinea-pigs are 
all susceptible; birds and dogs are less so, while TETANUS ANTITOXIN 
TETANY 
be abundant. Quinin and iron should be freely 
administered; opium and morphin have, in many 
cases, been serviceable; chloral hydrate, chloro- 
form, Indian hemp, and tobacco have all been 
tried in turn, and sometimes with success. Hydro 
bromid of hyoscin has recently been highly 
recommended in the treatment of convulsions. 
Large doses of bromid of potassium and chloral 
are also used. Should suffocation be threatened 
from spasm of the glottis, inhalations of nitrite of 
amyl should be resorted to: the usual quantity 
administered is from 5 to 10 minims. From a 
physiologic standpoint, calabar bean is the drug 
that deserves the most attention, as it is antago- 
nistic to the tetanic spasms caused by strychnin. 
It has, however, not proved to be a specific for 
tetanus. Extract of physostigma, 1/8 grain, may 
be given every hour until complete contraction of 
the pupil occurs, and this must be followed by 
stimulants to counteract the resulting depression. 
Intraspinal injections of magnesium sulphate 
suggested by Meltzer have been used with success 
in some cases. The danger of respiratory pa- 
ralysis is combated by the administration of 
oxygen and artificial respiration long continued 
if necessary. 
Specific Treatment.-This consists in the use 
of the antitetanic serum along with the other 
treatment. The dose is 10 to 20 c.c. of fresh 
serum, every 4 to 12 hours according to the se- 
verity of the symptoms. Results have not been 
better because generally the treatment is begun 
too late. In any suspected case the serum should 
be administered at the earliest possible moment 
after the infliction of the wound. As tetanus 
antitoxin is harmless it should be used as a pro- 
phylactic measure, a dose of at least 5000 units 
being given. The subarachnoid injections of 
magnesium sulphate should be used in connec- 
tion with the injections of tetanus antitoxin. 
TETANUS ANTITOXIN.-See Serum Therapy. 
TETANUS, INFANTILE.-Tetanus occurring in 
infants, as in adults, is an acute infectious disease 
due to a certain bacillus (Nicolaier's bacillus) 
which has its habitat in the soil. The germ of 
tetanus usually gains access to the body of the 
infant through the umbilical wound. Tetanus 
is rare except when dirt and filth prevail, but 
these alone are not sufficient to produce the 
disease. 
Symptoms.-These usually begin on the fifth 
or sixth day or at the time of the separation of 
the cord. The first symptom may not appear 
before the tenth or twelfth day, but seldom later, 
and the first thing noticed is a difficulty in nurs- 
ing, due to the rigidity of the jaws. The muscles 
of the jaws and face are hard and firm. Soon a 
slight stiffening of the body occurs, the child re- 
maining rigid for a short time, but relaxing during 
the intervals. These paroxysms soon increase in 
extent and frequency; the whole body becomes 
rigid and stiff; the arms are extended, the thumbs 
turned in, and the hands clenched. The thighs 
and legs are extended and no motion is possible 
at the hip or knee. The jaws may become firmly 
closed, and food cannot be taken. The pulse is 
rapid and weak, the temperature is more or less 
elevated (101° to 104° F.). The duration of 
fatal cases is very short (24 to 48 hours); but 
when recovery takes place, which is rare, the 
disease continues from 1 to 3 weeks, and the child 
usually suffers from malnutrition for some time 
longer. 
Treatment.-The preventive treatment con- 
sists in obstetric cleanliness and in especial care, 
in districts where tetanus is epidemic, that the 
cord is kept in a perfectly aseptic condition. 
Tetanus antitoxin should be given as soon as the 
slightest suspicion of the disease exists. The 
child should be kept in a very quiet, darkened 
room. During severe paroxysms inhalations of 
chloroform should be given until the patient is 
quiet. When the mouth cannot be opened, it 
may be necessary to introduce a wedge, so that 
nourishment can be taken. 
When unable to swallow, food should be intro- 
duced through a stomach-tube, which, when it 
cannot be passed through the mouth, may be 
inserted through the nose. Chloral hydrate 
should be given, and often large doses will be 
necessary. Beginning with 1 grain every hour, 
this may be increased, if the effects are not marked. 
The chloral should be well diluted in water, and 
may be given by the mouth or rectum. Extract 
of physostigma in 1/10-grain doses should be 
given hypodermically 3 times a day, or more 
frequently if necessary. 
TETANY.-Tetany is a form of tonic muscular 
spasm, affecting most commonly the muscles of 
the extremities, especially those of the hands 
and feet. It may occur at any age, but is most 
frequent during infancy. 
Etiology.-Tetany rarely occurs as a primary 
disease, but when occurring in infants, it is, in a 
majority of cases, associated with rickets, al- 
though in some cases it occurs with marasmus, 
chronic diseases of the intestinal tract, or some of 
the acute infectious diseases. The principal 
exciting cause is some irritation of the gastro- 
intestinal tract, as acute diarrhea, worms, pro- 
lapse of the rectum, or intussusception. In some 
cases teething may be the exciting cause. It has 
been known to recur among school-girls as an 
epidemic, in this respect resembling chorea. 
Symptoms.-The attacks consist of cramps of 
the muscles of the extremities. There is no 
loss of consciousness and, as a rule, no spasm of 
the facial muscles, but the face wears an expres- 
sion of pain when the cramps come on, and the 
infant screams when it is touched. The legs and 
arms are flexed and rigid, and the hands and 
fingers are tightly flexed. The feet may assume 
various positions of flexion, such as that of talipes 
equinus or equinovarus. The duration of the 
disease varies from a few minutes to hours or 
days. There is no loss of consciousness and no 
fever with the spasms. Laryngismus stridulus 
is quite often associated with tetany, as are 
also general convulsions. Tetany of itself is 
seldom fatal, but the prognosis of any case must 
depend upon the original disease that tetany may 
complicate. TETRONAL 
THERMOMETER 
Diagnosis.-The diagnostic features of the 
disease are bilateral spasms without loss of con- 
sciousness, the spasm in infants being usually 
limited to the hands and feet. 
Tetanus is to be distinguished from tetany by 
the fact that the former is a very rare disease, 
except in the new-born, etc., and that the attack 
begins with trismus, which does not occur in 
tetany. From meningitis tetany is distinguished 
by the fever and cerebral symptoms. 
Treatment.-When tetany is due directly to 
some digestive disturbance, as is usually the case, 
this should receive attention. A dose of castor 
oil (1 to 4 teaspoonfuls) should be given to clear 
out the intestinal tract, or, for the same purpose, 
calomel, 1/6 grain every 2 hours. 
If worms are suspected, the following should 
be given: 
the form of a double salt. In physiologic action 
it resembles caffein, being, however, free from 
any irritating action on the nerve-centers. See 
Caffein. 
Theobromin Salicylate.-C7H8N4O2. CO2. C6H4- 
OH. This occurs in small, white needles having 
an acid reaction and an agreeable bitter taste, 
and being slightly soluble in water. It is recom- 
mended as a substitute for diuretin in the same 
doses. The advantages claimed over the latter 
are that it is perfectly stable, and is not altered 
by air, moisture, or carbonic acid. See Diuretin. 
Theobromin Sodium Formate (Thephorin).-A 
powerful diuretic said to be free from irritant 
effects on the.stomach. Dose, 7 1/2 grains. 
Theobromin Sodium lodid (Iodotheobromin).- 
A white powder, soluble in water, decomposed 
by hot water. Used to increase arterial pressure; 
also as a diuretic. Dose, 8 grains. 
THEOCIN.-The trade name for synthetic 
theophyllin (dimeth ylxanthin), an organic base 
isomeric with theobromin. It is a white crystal- 
line powder. Like theobromin it differs from 
caffein in having but little effect on the central 
nervous system. 
Theocin has not so great a stimulant action on 
the heart as caffeine, but is a much more powerful 
diuretic than either caffein or theobromin. The 
diuretic effect, however, is not prolonged and its 
administration is, therefore, advantageously fol- 
lowed by one of the theobromin derivatives 
having a weaker, but more persistent, action. 
It occasionally produces gastric disturbances, and 
renal irritation has also been reported. In doses 
of 3 to 5 grains in warm tea, it is recommended in 
cardiac affections, nephritis, dropsy, etc. 
The double salt, acet-theocin-sodium, being 
more soluble, is said to be more readily absorbed 
and better tolerated than theocin. 
THERMODIN.-Phenacetin-urethane. An anal- 
gesic, antipyretic and antiseptic. It is said to be 
effective in typhoid fever and other febrile con- 
ditions, influenza, pneumonia, tuberculosis. It is 
claimed to produce no unpleasant by-effects. 
Dose, as an antipyretic, 5 to 10 grains, as an 
analgesic. 15 to 20 grains. 
THERMOMETER.-An instrument for measur- 
ing the intensity of heat, consisting of a reservoir 
of mercury (or of alcohol) expanding into a 
vacuous capillary tube, the intensity being meas- 
ured by the length of the column of mercury. 
Varieties.--Centigrade (or Celsius), one in which 
the freezing-point is at 0° and the boiling-point 
at 100°. Fahrenheit, one in which the interval 
between freezing and boiling is divided into 180 
equal parts, each called a degree, the zero-point 
being 32 degrees or divisions below the freezing of 
water. The freezing point is 32°, and the boiling 
point 212°. Reaumur, one in which the freezing- 
point is 0°, and the boiling-point 80°. 
Comparison of Thermometers.-To convert the 
registration of one thermometer into that of 
another, the following formulas are useful: 
Let F = number of degrees Fahrenheit. 
Let C = number of degrees Centigrade. 
Let R = number of degrees Reaumur. 
I). Calomel, gr. j 
Sodium bicarbonate, 
Milk-sugar, 
Powdered santonin, 
each, gr. vj. 
Make 12 powders, giving 1 every 2 hours, 
until 3 are taken, and repeat every other 
day. 
For the attack a hot bath is very effective, and 
sodium or potassium bromid, in 5- to 15-grain 
doses, should be given until the child is quiet, 
but continuing the bromid in small doses as long 
as any nervous symptoms remain. 
Following the attack, the child's general nutri- 
tion should receive careful attention. 
TETRONAL. - Diethylsulphondiethylmethane. 
A disulphone of the ethyl and methyl groups, 
harmless in ordinary doses, and having marked 
hypnotic properties. Dose, 10 to 30 grains. 
TETTER.-See Eczema. 
THALLIN.-A synthetic chemic product and a 
derivative of coal-tar. It is a powerful anti- 
pyretic, but its effects are not so lasting as those 
of antipyrin. It is likely to produce collapse. 
Dose of thallin or its sulphate, about 5 grains. 
THEA. THEIN.-See Caffein, Tea. 
THEOBROMA.-A genus of plants of tropical 
America. T. cacao is the cacao plant, or chocolate 
tree. See Cacao-butter. T., Cera turn ("red- 
lip salve"), cacao-butter, white wax, of each, 
35; oil of almond, 30; oil of rose, to flavor, and 
carmin, to color, a sufficient quantity of each. 
T., Oleum, butter of cacao. The fixed oil of the 
seed of the chocolate tree, T. cacao. It consists 
mainly of stearin, with a little olein, and is demul- 
cent, not becoming rancid. It is used in making 
suppositories. 
THEOBROMIN.-C7H8N4O2. An alkaloid oc- 
curring in the seeds of Theobroma cacao (1.5 
percent), obtained from the pressed cacao mass 
by mixing with slaked lime and exhausting with 
8 percent boiling alcohol. It is a white, crystal- 
line powder, slightly soluble in water, alcohol, and 
ether. Theobromin is a homolog of caffein, differ- 
ing in containing one CH2 group less; it unites 
readily with alkalies, forming soluble salts. See 
Diuretin. Because of its insolubility, theo- 
bromin is unsuitable for use, but is employed in THERMOMETER 
THIGH, AMPUTATIONS 
Then: 
C° = (F° -32) 
mometric observation. The mouth, the rectum, 
or even the vagina may be utilized. When in- 
serted in the mouth, the thermometer should be 
placed under the tongue, and the lips should be 
tightly closed. Great care is to be exercised that 
the instrument does not slip too far into the 
rectum when rectal temperature is taken. The 
thermometer should be introduced 2 inches deep, 
or above the internal sphincter, the patient lying 
on the side, the thermometer being kept in situ by 
one hand, letting the other rest on the hip of the 
patient to arrest any turning movement which 
might be made. To remove the instrument, it 
may be gently pushed forward a little to bring 
the bulb in contact with a fresh part of the mucous 
membrane, a part that has not been cooled by the 
thermometer. A practical caution is that the 
thermometer should not be introduced into a 
mass of feces which may fill the rectum. The 
inguinal fold or the fold of skin between the 
thumb and second metacarpus may be used for 
special, but not for general, clinical purposes. 
The clinical thermometer should be washed after 
usage. See Temperature. 
THIGENOL.-The trade name of a solution of 
sodium sulphite in a synthetic sulphuretted oil 
containing 10 percent of sulphur in organic com- 
bination. It occurs as a dark-brown, syrupy fluid, 
soluble in distilled water, alcohol, or glycerin. It 
is odorless and almost tasteless, and is used locally 
in eczema, seborrhea, acne rosacea, and other skin 
diseases. Dose, 3 to 10 grains. 
THIGH, AMPUTATIONS.-In amputations 
through the shaft of the femur the mixed method 
(an anterior skin flap with a shorter posterior one 
by transfixion) answers so well that any other is 
seldom needed. Care must be taken not to slit or 
prick the artery as it is passing out of Hunter's 
canal, and in arranging the dressings it must be 
remembered that, owing to the rotation of the thigh, 
the flaps very soon assume a lateral position. 
Amputation through the condyles may be per- 
formed according to either Carden's or Stokes' 
method. The section of the bone in the former 
runs through the base of the condyles, and the 
anterior flap passes across the limb midway 
between the apex of the patella and the tubercle 
of the tibia; in the latter the bone is divided above 
the condyles (supracondyloid), and the anterior 
flap reaches down to the tubercle, the increased 
length being required by the patella, the sawed 
surface of which is removed, so that it may face 
and become adherent to the cancellous tissue of 
the femur. They are both far superior to Ampu- 
tation through the thigh, owing to their enabling 
the pressure to be borne (in part, at least) on the 
face of the stump and their preserving the insertion 
of the adductor, and, in Stokes', the insertion of 
the extensor muscles. Gritti's amputation is 
similar to Stokes', but the bone is divided 1/2 inch 
lower, and the patella does not fit so well. In 
Carden's operation there is no posterior flap; in 
Stokes' the posterior flap is nearly as long as the 
anterior, and is cut either by dissection or trans- 
fixion, according to the bulk of the limb. See 
Amputation. 
£ 
C°= , R° 
4 
o 
F3 = -*CP + 32 
o 
F° = 9r° + 32 
R°=*C3 
o 
R°= o (F° -32) 
y 
The following is a comparative table: 
212 
210 
208 
206 
204 
202 
200 
198 
196 
194 
192 
190 
188 
186 
184 
182 
180 
178 
176 
174 
172 
170 
168 
166 
164 
162 
160 
158 
156 
154 
152 
150 
148 
146 
144 
142 
140 
138 
136 
134 
132 
130 
128 
126 
124 
Fahr. 
100 
98.9 
97.8 
96.7 
95.6 
94.4 
93.3 
92.2 
91.1 
90 
88.9 
87.8 
86.7 
85.6 
84.4 
83.3 
82.2 
81.1 
80 
78.9 
77.8 
76.7 
75.6 
74.4 
73.3 
72.2 
71.1 
70 
68.9 
67.8 
66.7 
65.6 
64.4 
63.3 
62.2 
61.1 
60 
58.9 
57.8 
56.7 
55.6 
54.4 
53.3 
52.2 
51.1 
Cent. 
80 
79.1 
78.2 
77.3 
76.4 
75.6 
74.7 
73.8 
72.9 
72 
71.1 
70.2 
69.3 
68.4 
67.6 
66.7 
65.8 
64.9 
64 
63.1 
62.2 
61.3 
60.4 
59.6 
58.7 
57.8 
56.9 
56 
55.1 
54.2 
53.3 
52.4 
51.6 
50.7 
49.8 
48.9 
48 
47.1 
46.2 
45.3 
44.4 
43.6 
42.7 
41.8 
40.9 
Reau. 
122 
120 
118 
116 
114 
112 
110 
108 
106 
104 
102 
100 
98 
96 
94 
92 
90 
88 
86 
84 
82 
80 
78 
76 
74 
72 
70 
68 
66 
64 
62 
60 
■ 58 
56 
1 54 
52 
50 
48 
46 
44 
42 
I 40 
1 38 
36 
Fahr. 
50 
48.9 
47.8 
46.7 
45.6 
44.4 
43.3 
42.2 
41.1 
40 
38.9 
37.8 
36.7 
35.6 
34.4 
33.3 
32.2 
31.1 
30 
28.9 
27.8 
26.7 
25.6 
24.4 
23.3 
22.2 
21.1 
20 
18.9 
17.8 
16.7 
15.6 
14.4 
13.3 
12.2 
11.1 
10 
8.9 
7.8 
6.7 
5.6 
4.4 
3.3 
2.2 
1.1 
Cent. 
40 
39.1 
38.2 
37.3 
36.4 
35.6 
34.7 
33.8 
32.9 
32 
31.1 
30.2 
29.3 
28.4 
27.6 
26.7 
25.8 
24.9 
24 
23.1 
22.2 
21.3 
20.4 
19.6 
18.7 
17.8 
16.9 
15 
15.1 
14.2 
13.3 
12.4 
11.6 
10.7 
9.8 
8.9 
8 
7.1 
6.2 
5.3 
4.4 
3.6 
2.7 
1.8 
0.9 
Reau. 
32 
30 
28 
26 
24 
22 
20 
18 
16 
14 
12 
10 
8 
6 
4 
2 
0 
-2 
-4 
-6 
-8 
-10 
-12 
-14 
-16 
-18 
-20 
-22 
-24 
-26 
-28 
-30 
- 32 
-34 
-36 
-38 
-40 
-42 
1-44 
-46 
-48 
-50 
-52 
-54 
-56 
Fahr. 
0 
-1.1 
-2.2 
-3.3 
-4.4 
-5.6 
-6.7 
-7.8 
-8.9 
-10 
-11.1 
-12.2 
-13.3 
-14.4 
-15.6 
-16.7 
-17.8 
-18.9 
-20 
-21.1 
-22.2 
-23.3 
-24.4 
-25.6 
-26.7 
-27.8 
-28.9 
-30 
-31.1 
-32.2 
-33.3 
-34.4 
-35.6 
-36.7 
-37.8 
-38.9 
-40 
-41.1 
-42.2 
-43.3 
-44.4 
-45.6 
-46.7 
-47.8 
-48.9 
Cent. 
0 
-0.9 
-1.8 
-2.7 
-3.6 
-4.4 
-5.3 
-6.2 
-7.1 
-8 
-8.9 
-9.8 
-10.7 
-11.6 
-12.4 
-13.3 
-14.2 
-15.1 
-16 
-16.9 
-17.8 
-18.7 
-19.0 
-20.4 
-21.3 
-22.2 
-23.1 
-24 
-24.9 
-25.8 
-26.7 
-27.6 
-28.4 
-29.3 
-30.2 
-31.1 
-32 
-32.9 
-33.8 
-34.7 
-35.6 
-36.4 
-37.3 
-38.2 
-39.1 
Reau. 
The clinical thermometer is a small, maximum, 
self-registering, mercurial thermometer, used in 
obtaining the temperature of the body. In its 
usual form the range of scale is about 15° F., and 
graduation is carried to one-fifth of a degree. 
The bulb is of extremely small diameter and fine 
bore, in which the mercury is rendered visible 
by a lens-fronted stem. The best clinical thermo- 
meters register in 30 seconds, but to secure suffi- 
cient accuracy it is generally desirable to allow 5 
minutes to elapse before removing the ther- 
mometer from the mouth or axilla. Especially in 
obscure cases is this desirable. 
The axilla is the locality most suitable for ther- THIGH, FRACTURES 
THIGH, FRACTURES 
THIGH, FRACTURES.-Fracture at the upper 
end of the femur is a frequent injury, and is of great 
practical importance. The neck of the femur is 
situated in large part within the joint capsule; 
hence, pure intracapsular fracture may occur. 
Fracture nearer the base of the neck may be en- 
tirely extracapsular, but, as a rule, the line of such 
a fracture is oblique to the long axis of the neck, 
and the fracture is partly extracapsular and partly 
intracapsular, or "mixed." 
shaft in women, this fragility explains the more 
frequent occurrence of this fracture in women than 
in men. 
Impaction of the thin portion of the neck into 
the head (intracapsular fracture) or of the neck 
into the trochanter (extracapsular fracture) is 
likely to result if the force producing the fracture 
acts in the direction of the long axis of the neck. 
Such impaction prevents the occurrence of several 
of the physical signs of fracture (abnormal 
mobility, crepitation); and when it occurs, 
no effort should be made to disengage the 
fragments. Clinically, such impacted frac- 
tures resemble incomplete fractures of the 
neck of the femur. 
The symptoms of fracture of the neck of 
the femur are sometimes very obscure, a 
positive diagnosis often being impossible. 
Fracture is probable when a person of ad- 
vanced age is unable to walk after receiving 
a fall, and when the injured leg is rotated 
outward and is more or less shortened. In 
forward luxation of the femur the leg is fixed 
elastically in outward rotation, while in fracture 
of the neck the rotation can be readily overcome, 
but the limb immediately drops back outward on 
being released. In incomplete or impacted frac- 
ture this outward rotation is less marked. 
The higher position of the trochanter, deter- 
mined by the comparative relationship to Nelaton's 
line, is a matter of great importance. If there is 
Mode of Applying Stirrup for Weight-Extension . 
This fracture results generally from a fall upon 
the hip: (1) upon the trochanter, the fracture 
resulting generally being at the base of the neck 
(extracapsular), impaction not infrequently occur- 
ring into the trochanter; (2) upon the extended 
knee or leg, such fracture generally being intra- 
capsular. Extensive rotatory movements may 
likewise cause fracture, through tension and 
Bed Used in Fracture of the Thigh.-(Bullitt.) 
traction of the iliofemoral ligament (fracture by 
traction). These fractures occur frequently in 
old persons-most frequently in old women. 
This is due to the fragility of the bones in advanced 
age, which is especially pronounced at the upper 
end of the femur. The bones become fragile 
earlier in women than in men; and, together with 
the sharper angle that the neck forms with the 
shortening of the injured side, measuring from the 
anterior superior spine of the ilium to the knee, 
and if the distance from the tip of the trochanter 
to the knee is the same on both sides, manifestly 
the seat of the shortening must be in the neck of 
the femur. 
It may happen that no fracture is sustained at 
the time of the fall, only a severe contusion, which, THIGH, FRACTURES 
THIGH, FRACTURES 
however, markedly interferes with the nutrition 
of the head of the femur and of the contiguous 
portion of the neck; the result of this may be a 
complete breaking down of the bone structure, 
and the appearance of a fracture secondarily. 
This occurrence is rare, but does undoubtedly take 
place. Movements of the injured thigh, are usually 
possible in all directions, are painful, and elicit 
crepitation when the fragments are loose and 
remain in contact. In rotating the thigh the shaft 
of the femur turns about its long axis in extra- 
capsular fracture, whilein intracapsular it turns 
about a radius equal in length to the intact 
portion of the neck of the femur. The X-rays 
should be employed in all these cases and will 
remove all possible doubt as to the character and 
extent of the injury. 
Treatment.-These patients are generally old, 
and therefore treatment is complicated by the 
attained by means of sand-bags placed along the 
inner and outer sides of the limb. Comfort or 
necessity may demand the addition of a Buck's 
extension apparatus (adhesive-plaster straps, 
weight, and pulley). In the ordinary loose frac- 
ture, with displacement, reposition must first be 
carefully effected; then a Buck's extension appa- 
ratus applied, the foot preferably being held 
fast and controlled by means of a sliding foot-rest 
to which the foot is made fast, thus preventing the 
tendency to outward rotation. A weight of from 
10 to 15 pounds ordinarily serves to maintain the 
fragments in good position. This weight and 
pulley method is especially admirable in that it 
permits mobility of the limb and the assumption 
of a semirecumbent attitude, without injury or 
pain. 
Plaster-of-Paris and hip splints of leather are 
applicable only when the patient is able to leave 
necessity of preserving and improving general 
health and nutrition, and of guarding against the 
occurrence of an asthenic hypostatic pneumonia, 
which may easily prove fatal. Frequent change 
of position is indicated-sitting up, turning from 
side to side, deep breathing, and, finally, early 
walking with the aid of ambulatory splints. This 
last is most readily accomplished by means of a 
spica of plaster of Paris; the sole of the shoe on 
the sound side is raised, and then a pair of crutches 
permit locomotion without disturbing the injured 
hip. In intracapsular fracture the fragment 
composed of the head is so poorly nourished 
that bony union is exceptional, fibrous union the 
rule. In extracapsular fracture callus-formation 
is likely to be abundant, and so bony union is the 
rule. 
In impacted fracture, or in loose fracture with- 
out tendency to displacement and outward 
rotation, the indicated and necessary rest is readily 
The Bed Tilted Laterally. 
the bed, intermittingly at least. The majority 
of these patients are old and feeble, so a brilliant 
final result is seldom to be expected; most of them 
do very well if they learn to walk again with a 
limp and a cane after the expiration of 6, 8, or 
more weeks. 
The serious difficulty in the treatment of these 
cases is the maintenance of rest of the injured 
hip in good position, at the same time providing 
for frequent shifting of the patient's position, 
combating the hypostatic tendency. The hip 
must, therefore, frequently be sacrificed to the 
patient's life. The accompanying illustrations 
show a bed designed by Bullitt for meeting this 
very difficulty. The bed is so arranged that the 
whole bed plane can be tipped from side to side, 
and the head can be raised to an almost upright 
position -without any movement on the part of 
the patient. The utility of this contrivance in 
the handling of such cases is obvious, and practical THIGH, FRACTURES 
use^has demonstrated its great value. The 
working and uses of the bed are illustrated by the 
cuts made from photographs. The first cut 
shows the bed for use as an ordinary bed. The 
second cut shows the bed plane tilted laterally, 
thereby shifting the weight from the back to the 
side. Small, firm, hair pillows are packed in 
between the patient and the side bar, and so the 
patient does not move or slip while the change in 
position is being effected. The third cut shows 
the bed-frame tilted lengthwise; this position is 
especially designed for the treatment of fractures 
of the thigh and hip in old persons. The foot of 
the sound side is supported by two small and firm, 
hair pillows inserted between it and the foot-board, 
so permitting the foot of the injured side to swing 
relatively thick periosteum remaining intact usually 
prevents marked displacement. The fracture line 
is generally oblique, and longitudinal traction of 
the powerful thigh-muscles easily effects displace- 
ment, which is sometimes extreme. Abnormal 
mobility is readily demonstrated; likewise crepita- 
tion. If crepitation cannot be demonstrated, 
especially after reposition, it is presumable that 
soft parts are interposed between the fragments; 
correct and bony union cannot be expected unless 
the fragments are brought into good apposition. 
A typical displacement accompanies fractures 
above the middle of the shaft. The upper 
fragment is carried into flexion by the iliopsoas 
muscle, and into abduction by the glutei muscles; 
at the same time the lower fragment is drawn 
THIGH, FRACTURES 
The Bed Tilted Lengthwise. 
free. Elevation can be accomplished to almost 
an upright position, though such a degree of 
elevation would probably seldom be employed. 
The great trochanter is rarely separated as a re- 
sult of direct force. When separation occurs, it is 
recognizable through the displacement, the frag- 
ment being felt behind and above the glutei 
muscles, with a wide diastasis between it and the 
femur. The muscular traction makes it difficult to 
hold the fragment in place by dressings. In case 
of failure, it only remains to fix the fragment in 
place directly by means of suture or nails. In 
any event, the thigh should be kept in abduction. 
Fractures of the diaphysis of the femur in its 
middle third, or just above the middle, are fre- 
quent. Some are due to torsional force, but the 
greater number to bending by direct force (run- 
over accidents). In this locality displacement is 
generally considerable in the adult; in children the 
upward and inward by the hamstrings and the 
adductors. This projection of the upper fragment 
forward and outward is to be carefully borne in 
mind when effecting reposition and fixation; other- 
wise the deformity will be found persisting after 
the consolidation of the fracture. 
Treatment.-In the treatment of fractures of 
the diaphysis permanent extension, by means of 
adhesive-plaster straps, weight and pulley (Buck's 
extension apparatus), is of the very greatest 
usefulness, and tends to greatly simplify treat- 
ment. The adhesive-plaster straps are to have 
broad surfaces, and should be capable of support- 
ing a weight of from 20 to 25 pounds, which is 
necessary to overcome the upward muscular trac- 
tion. Pillows and sand-bags sometimes suffice to 
support and further control the position of the 
limb; usually, however, it will be found best to 
support the fragments by means of short splints THIGH, FRACTURES 
padded and securely bound to the thigh over the 
extension apparatus. The addition of a sliding 
footboard is sometimes necessary properly to 
control the rotatory tendency of the lower leg. 
In fracture with a short upper fragment the dis- 
placement already referred to (forward and out- 
ward) is difficult to combat. Here the 
double inclined plane of Agnew is of good 
service, together with an extension appa- 
ratus acting on the thigh from the knee 
upward and making traction in the direc- 
tion of the displacement of the upper frag- 
ment forward and outward. Perhaps the 
best support of all is by means of molded 
leather splints in combination with Buck's 
extension apparatus. The splint is cut from 
saddle skirting leather and is made of a shape 
to extend from the knee well up over the hip 
and to cover the anterior and outer aspects 
of the limb. The leather is immersed in hot 
water (hot as the hand can bear), and is 
then molded to the part, being held in place 
for a few minutes by means of a roller band 
age. It is then removed and dried before 
the fire for a short time, when it will retain 
its shape. The extension apparatus is now 
applied, reposition is effected, and the leather 
splint is securely bound to the limb. It is 
necessary from time to time to measure the 
two thighs from the anterior superior spine to the 
patella, guarding in this way against the occurrence 
of any excessive shortening. 
Ordinarily, at the end of 4 weeks consolidation is 
far enough advanced to change the dressing to one 
of plaster of Paris, which permits 
locomotion and is worn for 4 weeks 
more. 
In children the method of verti- 
cal suspension of the whole limb 
(or better, of both limbs) is a most 
excellent one. Vertical suspension 
is also applicable in adults when 
it is found otherwise impossible to 
preserve the proper position of the 
fragments. 
In new-born children almost the 
only possible way to fix the thigh 
is in the position of the fetus in 
utero, with the thigh flexed against 
the abdomen and held there by 
means of adhesive-plaster straps. 
This dressing permits the ready handling and 
cleansing of the child. 
Every fracture of the thigh is likely to be 
attended by greater or less permanent shortening 
of the limb. 
Compound fractures, which require frequent 
change of dressings, are very conveniently treated 
by means of the suspending splint of Hodgen. 
Fractures at the lower end of the femur are rarer 
than those of the shaft and neck, and result from 
direct violence. 
In supracondylar transverse fracture the lower 
fragment is drawn downward in flexion by the 
calf-muscles, while the traction of the thigh- 
muscles tends to increase the overriding of the 
fragments and the marked displacement. In 
epiphyseal separation similar displacement occurs, 
although slighter in degree, because the periosteal 
covering remains intact, in part, at least. The 
knee-joint may be involved, and certainly is if 
the lower fragment becomes split longitudinally- 
THIOCOL 
Hodgen's Suspension Splint.-(Moullin.) 
T-fracture. The vessels and the sciatic nerve 
are in danger of injury from the sharp edges of 
the displaced lower fragment. Abnormal mobility 
and crepitation readily determine the nature of 
the injury. After requisition it is manifest that 
the mechanically correct position is one of flexion, 
more or less acute, whereby the tendency of the 
lower fragment to recurrent displacement is best 
overcome. This may be accomplished by a 
posterior angular splint or by the double inclined 
plane. Sometimes permanent extension is suit- 
able, together with gentle pressure from behind 
against the lower fragment. After 4 or 5 weeks 
passive motion should be instituted, and further 
treatment, as for articular fracture elsewhere, 
should be given. 
Fracture of one condyle is necessarily intra- 
articular, and is recognizable by the to-and-fro 
movements at the knee, by crepitation and by the 
localized pain. Hemorrhage into the joint may 
be profuse, and if so, the blood should be evacu- 
ated by aspiration. An extension dressing with a 
posterior splint is best, or a double inclined plane 
may be used. Care must be taken to counteract 
any varus or valgus tendency that may become 
manifest. 
THIOCOL.-The potassium salt of guaiacol 
sulphonic acid. It contains about 60 percent of 
guaiacol, and is in the form of a fine, white powder, 
which has a taste at first bitter, then sweetish. 
It is used in diarrhea, pneumonia, and all forms 
of tuberculosis. As advantages over other reme- 
dies may be mentioned: Entire freedom from 
odor, great solubility in water, ready absorption, 
and freedom from irritant action on the mucou. 
membranes. It is claimed that these properties 
make it applicable for the most sensitive patients. 
Bryant's Ver- 
tical Extension 
for Fracture of 
Femur in Chil- 
dren. THIOL 
THYMOL 
Dose is from 7 to 30 grains, up to 1 1/2 drams or 
even 4 drams daily. Daily doses of from 150 to 
225 grains may be continued for a considerable 
time without disadvantage, which is of the 
greatest importance in the creosote treatment. 
It causes no nausea or diarrhea. 
THIOL.-Prepared by the sulphuration of 
certain nonsaturated hydrocarbons, and is a 
product very similar to ichthyol. It occurs in 
both dry and liquid form, the former, Thiolum 
siccum, as dark-brown lamellae or powder, of 
bituminous odor and bitter, astringent taste; 
soluble in water and in chloroform, sparingly in 
alcohol, insoluble in ether and in benzin. The 
liquid form, Thiolum liquidum, is a dark-colored, 
syrupy fluid, miscible in all proportions with 
water. Dose, internally, 5 to 30 grains. 
The dry form is used as a dusting powder in 
erysipelas, eczema, erythema, intertrigo, impetigo, 
pemphigus, periphlebitis, subcutaneous hemor- 
rhages, and syphilitic ulcers. It is an efficient 
application in pelvic exudations and endometritis. 
Thiol causes neither pain, burning, nor other 
symptoms of irritation, nor any bleeding from 
eroded surfaces. 
Glycerinated thiol is a remedy for chilblains, 
consisting of equal parts of liquid thiol and 
glycerin. 
THIOSINAMIN.-Allyl-sulpho-carbamid. It is 
prepared by heating together oil of mustard 3, 
alcohol 3, and ammonia 6. It occurs as colorless 
crystals, which are very soluble in alcohol and in 
ether, and moderately so in water. The addition 
of antipyrin in one-half the quantity renders it 
soluble in water to the extent of 15 percent 
(Michel). It produces a local reaction when 
injected for lupus, or where sclerotic tissue is 
present, which it softens and permits of its absorp- 
tion. It is used for the removal of scars, corneal 
opacities, and keloid; also for lupus, fibrous 
deposits in joints, stenosis of the esophagus, and 
for deafness due to thickening of the drum or 
fixation of the aural bones. Dose, 1/2 to 1 grain, 
thrice daily by mouth; or 10 to 20 minims of a 
10 percent solution in absolute alcohol, hypoder- 
mically every third day. The ethyl-iodid of 
thiosinamin is said to be of service in arterio- 
sclerosis, asthma, emphysema, scrofula and 
syphilis, given internally in doses of 2 grains 
several times a day. 
THIRST.-The state manifested by a desire 
for drink. It is marked by dryness of the mouth 
and fauces, together with constriction of the 
pharynx and esophagus. 
Although referred to the back of the throat, 
thirst is not a purely local feeling, since it cannot 
be allayed until fluid reaches the stomach and is 
absorbed. In febrile disorders, after hemorrhage 
or operation, in cholera and diarrhea, in diabetes 
mellitus, and in acute and chronic gastritis thirst 
is usually present. It forms a useful diagnostic 
sign between chronic gastritis and mere atonic 
dyspepsia. 
Remedies that allay thirst and impart coolness, 
such as the vegetable and mineral acids, ice, water, 
if cold, effervescing drinks, fruit-juices, and many 
diaphoretics are called refrigerants. Acid drinks 
allay thirst by promoting the secretion of alkaline 
saliva, but when excessively used, they will 
derange the stomach. Cracked ice, sucked, is 
very grateful, and allays thirst in fever. Fruit- 
juices, or those made into drinks, must be used in 
moderation: excess will do harm. Bitters, in 
drinks with acids, most effectually slake the 
thirst. A weak infusion of orange-peel acidulated 
with hydrochloric acid makes an efficient thirst- 
queller in fever patients. Tepid drinks are useful 
in the thirst of diabetes. 
THOMSEN'S DISEASE.-See Myotonia Con- 
genita. 
THORACIC DUCT, AFFECTIONS. Diseases.- 
Narrowing may result from inflammation of the 
coats or blocking of the lumen by pressure of an 
aneurysm, tumor, or contracting cicatrices, or 
from cancerous or tubercular material. Complete 
obliteration need not cause death or even marked 
symptoms, since the veins seem to act vicar- 
iously. Aneurysm of the duct and dilatation 
and calcification of the walls have also taken 
place. A primary growth in the duct has not 
been recorded. 
Injuries.-The thoracic duct has occasionally 
been torn or wounded. In such cases a discharge 
of a spontaneously coagulating fluid, milky 
during digestion, has taken place. In one instance 
the fluid escaped into the pleural cavity, which 
had to be tapped repeatedly. A diagnosis of 
injury to this duct is impossible save by evidence 
of this chylous fluid escaping or being tapped 
from the pleural cavity. The prognosis is of the 
utmost gravity, as death is the general rule, in 
weeks rather than months, and from marasmus. 
In one case the opening in the duct was said to 
have healed under a plug. In another case a 
clamp was made use of, and packing of the cavity 
around this with gauze resulted in recovery. 
See Chest (Injuries). 
THORACOPLASTY.-See Pleurisy (Treat- 
ment). 
THORAX.-See Chest. 
THREAD-WORMS.-See Worms. 
THROAT.-See Esophagus, Larynx, Neck, 
Pharynx. 
THRUSH.-See Stomatitis (Parasitic). 
THUMB.-See Hand and Fingers. 
THYME.-A plant of the genus Thymus. 
Oil of Thyme is a stimulant and antiseptic oil 
containing thymol; chiefly used topically in 
veterinary practice. 
THYMOL.-C10H13HO. A phenol with active 
antiseptic and anesthetic properties. It exists 
in oil of thyme and other vegetable oils. It 
occurs in large, colorless plates, melting at 44° C. 
and boiling at 230° C. It has a thyme-like odor, 
and is slightly soluble in water but readily soluble 
in alcohol. Thymol is chiefly employed as a 
gargle, spray or inhalation in laryngitis and 
diphtheria; as an ointment in ringworm, eczema 
and psoriasis, and as an injection in ozena. A 
solution of 1 part in 1000 is the strength usually 
prescribed. Internally it has been used with 
success in diphtheria, typhoid fever and other THYMUS GLAND 
THYROID GLAND, DISEASES 
intestinal affections, diabetes, phthisis and vesical 
catarrh. Its fragrant odor renders it a very agree- 
able antiseptic application for ulcerated conditions 
of the mouth and fauces, but makes it very attract- 
ive to flies, which fact together with its high price 
will prevent it becoming a favorite in hospital 
practice. A solution, used as a mouth-wash, is 
very efficient in removing the odor of tobacco 
from the breath. Thymol is almost specific 
against the intestinal parasite ankylostomum 
duodenale (uncinaria Americana) for which it is 
given in three or four doses of 10 to 30 grains, 
well triturated, in capsules; care being taken that 
no alcoholic drink is ingested afterward, in order 
to avoid the absorption of thymol and consequent 
poisoning thereby. Dose, 1/2 to 3 grains. T. 
Inhalation, thymol, 20 grains; alcohol, 3 drams; 
magnesium carbonate, 10 grains; water; add 
enough to make 3 ounces; add a teaspoonful to a 
pint of water at 150° F. for each inhalation. 
T. lodid, See Aristol. T. Solution, for spray- 
ing, 1: 1000. T., Ung., contains 5 to 30 grains to 
1 ounce. Volkmann's Thymol Solution, thymol 1, 
alcohol 10, glycerin 20; and water 100. It is used 
as a spray and antiseptic lotion; it does not pro- 
duce eczema, as do phenol lotions. 
THYMUS GLAND.-See Status Lymphaticus, 
Neck (Injuries). 
THYMUS GLAND EXTRACT.-An animal ex- 
tract whose mode of preparation and dose are 
similar to those of thyroid extract. It has been 
serviceable in exophthalmos with anemia and 
debility, in leukemia, chlorosis, idiopathic and 
pernicious anemia, and in the so-called "status 
thymicus." 
THYRESOL.-The methyl ether of santalol. 
It is similar to sandal wood oil in its properties 
but is said not to produce gastric or renal irrita- 
tion. It is recommended in the treatment of 
gonorrhea, etc. Dose, 8 grains in milk or in 
gelatin capsules. 
THYROID EXTRACT.-See Thyroid Treat- 
ment. 
THYROID GLAND, DISEASES.-Colloid degen- 
eration, affecting the contents of the sacs and at- 
tended with atrophy of the cellular lining, is of 
so common occurrence as almost to be considered 
normal. Nothing is known with regard to its 
function beyond the general fact that the activity 
of growth and nutrition of all parts of the body 
(including the brain) are intimately connected 
with its integrity. In women it frequently en- 
larges and becomes tender-at puberty, during 
the menstrual period, and during pregnancy. 
Cretinism is, in all probability, due to its im- 
perfect development; removal during childhood 
causes a similar condition, and, in a large pro- 
portion of cases, removal of the whole gland is 
followed by myxedema, if performed on adults. 
The temperature falls; the oxygenating capacity 
of the blood diminishes; leukocytosis sets in; 
the coagulability is lessened; the skin and sub- 
cutaneous tissue undergo a peculiar transforma- 
tion; nervous symptoms (tremors, paresis, pares- 
thesia, etc.) make their appearance, and, at length, 
a cretinoid condition, with imbecility and coma, 
follows. When this does not take place, it is 
probably owing to the fact that the whole gland 
has not been removed, or that accessory thyroids 
(which are of very common occurrence) have 
undergone compensative hypertrophy. Some- 
times it follows with great rapidity shortly after 
the operation; sometimes, on the other hand, 
slowly and gradually. In a few instances the 
immediate onset, after a period of apparently 
perfect health, has been brought on by exposure 
to cold (Moullin). 
Inflammation may be acute or chronic, and in 
resolution or in suppuration and sloughing, 
according to the cause and the addition or not of 
pyogenic irritants. 
The symptoms, when the attack is acute, are 
very alarming, often beginning with a rigor and 
high fever. Owing to the way in which the gland 
is bound down by the cervical fascia the pain is 
very severe; the tissues of the neck are hard and 
rigid, the superficial veins distended, the trachea 
and esophagus compressed against the spine, and 
there may be cerebral symptoms caused by the 
obstruction to the cranial circulation. In most 
cases resolution sets in after 48 hours, and the 
acute symptoms begin to subside, but often the 
improvement is only partial; the diffuse enlarge- 
ment disappears, but one or more local swellings 
remain; the skin becomes red and edematous, 
and at length fluctuation is apparent. Death 
may occur from pressure upon the trachea, from 
pus finding its way down into the lungs, or from 
pyemia or septicemia. In one or two instances 
the gland has sloughed. 
The treatment must be energetic. At the onset 
aconite or antimony may be given internally in 
small, frequently repeated doses, until a distinct 
effect is produced upon the arterial tension. 
Ice-cold compresses should be placed upon the 
neck, the superficial veins pricked to relieve the 
circulation, and leeches applied to the supra- 
clavicular region. Venesection (either from the 
arm or the external jugular) may be advisable, if 
the patient is young and the inflammation sthenic. 
If signs of suppuration make their appearance, the 
superficial structures must be carefully divided, 
layer by layer, and a director used for exploration, 
after Hilton's method. A drainage-tube must be 
inserted to prevent the opening becoming valvular. 
Goiter, or Derbyshire neck, is an enlargement of 
the thyroid gland. It may be due, as is com- 
monly the case, to simple hypertrophy of the 
normal tissues of the organ (ordinary goiter), 
and may then involve the whole gland or one of 
the lateral lobes or rarely only the isthmus. In 
other instances the hypertrophy may fall chiefly 
on the fibrous tissue, constituting the septa of 
the gland (fibrous goiter). Or along with some 
amount of simple hypertrophy and increase of 
fibrous tissue (adenoma) one or more of the normal 
alveolar spaces may becomes enlarged, forming 
single or multiple cysts (cystic goiter). Such cysts 
contain, when single, a serous fluid, or when 
multiple, a colloid or a dark, grumous material 
sometimes mixed with altered blood; while occa- 
sionally, proliferating growths project into their THYROID GLAND, DISEASES 
THYROID GLAND, DISEASES 
interior from the cyst walls. In other instances 
again, but more rarely, the hypertrophy is 
associated with a great increase in the vessels, 
and a forcible and expansile pulsation is given to 
the gland {pulsating goiter'). But the tissues, 
besides hypertrophy, may undergo secondary 
changes. Thus, calcification may occur, and the 
enlarged gland become of stony hardness {calcified 
goiter) in places, or the fluid normally contained 
in the alveolar cavities may assume a colloid 
character. Lastly, the enlargement of the thyroid 
may be due to malignant disease {malignant 
goiter). In certain districts goiter is endemic, 
especially in the Rhone Valley in Switzerland, 
and in Derbyshire in England, and is then fre- 
quently associated with the condition known as 
cretinism. It also occurs sporadically; and in 
some cases again is accompanied by a peculiar 
jerking beat in the carotids, by anemia, and by a 
prominence of the eyeballs. See Exophthalmic 
Goiter. 
The symptom common to any form of enlarge- 
ment of the thyroid is a swelling taking more or 
less the characteristic shape of the thyroid gland, 
and moving with the larynx in deglutition. In this 
country the enlargement is generally moderate; 
but sometimes, and especially in Switzerland, the 
goiter forms a large mass hanging in front of the 
neck, and may press upon or even displace the 
trachea and esophagus. It occurs chiefly in 
women. In the ordinary variety it is soft, semi- 
fluctuating, and of uniform consistency; in the 
cystic one or more fluctuating places may be felt; 
while in the fibrous it will be firm and hard and 
more or less lobed or irregular, and when calci- 
fication has taken place, of stony hardness. 
Malignant goiter, which is very rare, may be 
known by rapid growth, enlarged glands, and the 
other signs of malignancy. 
The cause of endemic goiter is not known. It 
has been attributed to impure water, water from 
limestone, and snow water, but without conclusive 
evidence. It is said to be most prevalent in 
valleys where, from their direction, the sun does 
not penetrate, on damp soil, and in damp parts 
of towns; but, according to Berry, these influences 
have little or nothing to do with its causation. 
In sporadic cases heredity, disturbance of the 
sexual functions, and conditions producing con- 
gestion of the head and neck are given as causes. 
Treatment.-Sporadic cases of ordinary goiter 
should be treated by the internal and external 
application of iodin, and removal from the goitrous 
district. Thus the syrup of the iodid of iron may 
be given internally, and an ointment of iodin and 
iodid of potassium applied externally. The use 
of biniodid of mercury ointment, followed by 
exposure to a hot sun, has been attended with 
much success in India. An ice collar has some- 
times been of service. 
Cystic goiter may be treated by aspiration, 
drainage or enucleation. Of these the first is of 
little avail, except as a temporary expedient in an 
urgent case, or as a preliminary to other measures. 
The fluid must be drawn off very slowly, or hemor- 
rhage may occur from the delicate vessels in the 
walls of the sac, and fill it even more tensely than 
it was before. 
Drainage and enucleation are more successful. 
A linear incision is made through the superficial 
structures, and the capsule of the gland freely 
exposed. If there is a large single cyst, it can 
usually be enucleated by careful dissection, clamp- 
ing and dividing between two ligatures every 
vessel; solid adenoma may be treated in the same 
way. If this is impraticable, the cavity may be 
laid open and the contents cleaned out; but the 
operator must be prepared for severe hemorrhage. 
Plugging with iodoform gauze may be necessary 
if it does not stop at once. It does not appear to 
be necessary to fasten the edge of the cyst to the 
skin or the cervical fascia; according to Clutton, if 
the superficial structures are not disturbed or dis- 
placed, there is very little risk of inflammatory 
infiltration. If a number of small cysts are packed 
closely together, it is better to excise the part so 
long as it is not too large, ligating the vessels one 
by one as they appear, and taking especial care 
of the recurrent laryngeal nerve. 
Operative treatment consists in ligation of the 
thyroid arteries; division of the isthmus; removal 
of the isthmus or one lobe; or partial removal 
of both lobes. 
In beginning goiter ligation of the superior 
thyroid arteries has sometimes arrested the proc- 
ess of morbid growth. Division of the isthmus 
is a palliative operation for late cases in which the 
trachea is compressed. 
It may be stated as a general rule that every 
rapidly growing goiter should be removed. 
Timely recourse to operation will save the patient 
much trouble. Partial excision of the thyroid is 
the operation of choice. It is performed as 
follows: As little anesthetic as possible, and that 
chloroform or ether by the open method, should be 
given since dyspnea is liable to occur during the 
operation. On this account some surgeons em- 
ploy local anesthesia with cocain. An incision is 
made over the tumor along the anterior border of 
the sternomastoid when part only of one lobe is 
to be removed. If a part of both sides, then a 
curved incision across the front, so that the scar 
may be covered by a necklace. Then the sterno- 
mastoid is retracted, and the sternohyoid, sterno- 
thyroid split, or, along with the omohyoid, cut 
across, but as far from the line of the cutaneous 
wound as possible to prevent their adherence to 
the scar, which would then be puckered in every 
time the muscles contract. The tumor having 
been thus exposed, the fascia should be opened 
carefully so as not to injure the veins lying be- 
neath it. When necessary, the veins are divided 
between clamp forceps, and later tied. Enuclea- 
tion should now be begun with the finger, aided 
by a small sponge held in clamp forceps, bearing 
in mind that although the common carotid artery 
is pushed outward, the internal jugular vein usu- 
ally runs over the tumor, being held more or less 
in position by the veins opening into it. The pul- 
sation of the artery is therefore no guide to the 
position of the vein, which may run in front of, or 
internal to the artery. THYROID GLAND, INJURIES 
The superior thyroid arteries should be sought 
at the upper and inner part of the tumor and 
securely tied. Of the lower part of each lateral 
lobe a piece should be left, at least as large as the 
end of the thumb. In this way one may avoid 
injuring the recurrent laryngeal nerve which 
passes upward among the main divisions of the 
inferior thyroid artery. When the tumor has 
plunged behind the sternum, delicate manipula- 
tion is needed to isolate it from the pleura and 
innominate veins. After applying ligatures, the 
capsule may be drawn together by a purse-string 
suture, next the divided muscles should be sutured 
together if possible, and the skin united except for 
a small drain. 
Sarcoma or carcinoma arising in the thyroid 
gland, if it is to be removed must be diagnosed 
early. A tumor arising in the thyroid gland, in a 
patient over forty, especially in a man, and a 
gumma being excluded, should at once be explored, 
and removed early, while still within the capsule 
of the gland. 
THYROID GLAND, INJURIES.-See Neck 
(Injuries). 
THYROID TREATMENT.-The treatment of 
disease by the administration of thyroid gland or 
substances derived from it. 
Preparations.-(1) The fresh gland of the 
sheep, minced. (2) The thyroid glands of the 
sheep, freed from fat, and cleansed, dried and 
powdered (the desiccated thyroid glands of the 
U. S. P.). (3) Dry thyroid (thyroideum siccum 
of the British Pharmacopeia). This is prepared 
by removing the fat and connective tissue from 
the healthy gland taken from the sheep directly 
after it is killed. The gland is minced, dried 
at from 90° to 100° F., and powdered. Fat is 
removed by washing with petroleum spirit, 
and the powder dried. (4) Glycerin extract of 
thyroid (liquor thyroid of the British Pharma- 
copeia). The fresh, healthy thyroid glands of 
the sheep are bruised with 34 minims of glycerin 
and 34 minims of a 0.5 percent solution of phenol 
for each gland. The mixture is allowed to stand 
for 24 hours, strained, and sufficient of the phenol 
solution added to make 100 minims. (5) lodothy- 
rin. This is obtained by hydrolysis of the colloid 
matter of the gland with diluted caustic soda, and 
precipitation of the colloid by acetic acid. 
Dosage.-Of the raw gland, from 1/2 to 1 may 
be used. The dose of the U. S. P. preparation is 
4 grains. Three to 10 grains of dry thyroid and 
from 15 to 60 minims of the glycerin extract may 
be given twice or thrice daily. lodothyrin, as 
found in the shops, is rubbed up with sugar of 
milk and is administered in 5-grain doses. 
Method of Administration.-The transplantation 
of thyroid glands (greffe thyroidienne) as practised 
by Bettencourt and Serrano has been abandoned. 
The ingestion of minced, raw, or slightly warmed 
sheep's thyroids, even when seasoned, so speedily 
provoke nausea and vomiting that this method is 
impracticable for prolonged use. The dry pow- 
dered gland can be given as such or in capsule, 
wafer, or tablets by the mouth. The glycerin 
extract is most frequently employed when given 
by the mouth, or when sufficiently diluted, hypo- 
dermically. lodothyrin may be exhibited in 
substance, in capsule, wafer, or tablet, by the 
mouth or subcutaneously. The frequency varies 
from 2 to 3 times daily until the physiologic effects 
are obtained, then once daily or less frequently 
as may be necessary to maintain them. 
Physiologic Action.-The result of the adminis- 
tration of thyroid is to increase oxidation in the 
body, the nitrogenous substances being excreted 
entirely as urea, fats as carbon dioxid by the lungs 
and as water by the kidneys. Diuresis is a con- 
stant effect, and this is greater than can be 
accounted for by increased oxidation, so that it 
is evident that the tissues themselves are desic- 
cated. It is probable that the circulating proteids 
are first destroyed, while the fixed proteids are 
only attacked after the store of fat is considerably 
diminished. It is likely, considering the small 
quantity of thyroid administered, that these effects 
are brought about through the influence of the 
nervous system rather than by its direct action 
upon the tissues themselves. Since glycosuria is 
often a result of thyroid medication, it is likely 
that thissubstance may effect carbohydrate metab- 
olism, so as to diminish the power of the tissues 
to utilize sugar (Hutchison). Increased rapidity 
of the heart's action is very constant, and often 
there are observed irregularity, palpitation, and 
even weakness; the fall of blood-pressure is proba- 
bly due to the last-named condition rather than 
to dilatation of peripheral blood-vessels. As to 
its effects upon the blood, contradictory results 
have been observed. Probably small doses exert 
no influence, while large doses destroy blood- 
corpuscles. Making use of the colloid material, 
it may be said that excretion is entirely by the 
kidneys. This excretion is gradual, and may be 
continued for several days after its administration 
is stopped. Whether this material is excreted as 
such or is broken down in the organism is still an 
open question. 
Some differences are observed in the results of 
administration of different preparations. The 
most important are that iodothyrin seems to have 
no effect upon the heart as to its rate, rhythm, or 
vigor; and this is true of the intravenous injections 
of colloid matter. The fall of pressure on admin- 
istration of the gland or improperly prepared dry 
extracts is undoubtedly due to contained organic 
extractions, and it can be definitely stated that 
absolutely fresh thyroid gland is not poisonous 
when absorbed by way of the alimentary canal, 
lodin is readily detected in the urine of patients 
who are taking iodothyrin, while it is found with 
difficulty after administration of thyroid prepa- 
rations. The explanation doubtless is that normal 
thyroid stores up iodin and prevents its excretion. 
Inasmuch as there is no satisfactory method of 
standardizing thyroid preparations, the dose must, 
for the present, be determined from the results 
rather than the physician be guided by the poso- 
logy as found in the literature. 
Precautions in Administration.-Under the 
term "thyroidism" have been described symptoms 
that may be divided into 2 groups: (1) the ali- 
THYROID TREATMENT THYROID TREATMENT 
mentary-nausea, colicky pains, and diarrhea; (2) 
the metabolic-headache, pains and heaviness in 
the limbs, palpitation, disturbances of cardiac 
rhythm, and weakness. The first group may be 
due to products of putrefaction, to which the 
thyroid is especially liable, particularly if fever, 
sweating, and collapse are prominent. These can 
be avoided if the method of d'Arsonval (steriliza- 
tion in an autoclave by carbon dioxid, under a 
pressure of 50 atmospheres) is employed. The 
second group is probably the result of overaction 
of the substance itself, since idosyncrasy must 
always be taken into consideration. Symptoms 
may appear after the use of any preparation, and 
are the results of increased metabolism. The 
practical suggestion to be borne in mind is that 
small and frequent doses-instead of large ones 
at longer intervals-should be employed. Caution 
and good sense should be shown in the use of 
thyroid preparations, and they should always be 
administered by a physician. The result after 
thyroidectomy in the practice of surgeons, dem- 
onstrates the necessity of strict observance of this 
rule. As improvement is secured the interval 
between doses should be lengthened, until constant 
physiologic effects only are secured. 
Therapeutic Applications.-In the treatment of 
myxedema the use of the various preparations of 
the thyroid gland approaches nearer to specific 
action than any other in therapeutics, the results 
of mercury and the iodids in syphilis not even 
excepted. Inasmuch as in this disease the some- 
thing that through cessation of function of the 
thyroid is not supplied to the organism can be 
furnished by the administration of preparations of 
this gland, the cure of myxedema becomes an 
assured fact. This statement is accurate only in 
the understanding that continued administration 
is persisted in. The tangible results observed are: 
(1) Lessening of the physical and intellectual 
torpor; (2) increased urinary excretion; (3) resto- 
ration of body temperature to the normal; (4) re- 
absorption of the edema of face and limbs. (5) pro- 
gressive disappearance of difficulty of speech, 
interference with swallowing and muscular move- 
ments; (6) cessation of constipation; (7) diminu- 
tion of body weight; (8) cessation of trophic dis- 
turbances-as, for instance, falling of the hair. 
In other words, the nutrition is stimulated and 
the principal functions are regulated. 
The treatment may be divided into 2 stages: (1) 
curative and (2) prophylactic. In the first, daily 
doses should be persisted in until all symptoms 
have disappeared. If a preparation free from 
decomposition products is employed-and none 
other should be used-the amount given should 
bethat which does not affect the pulse-or pro- 
duce other untoward action. So soon as cure has 
been obtained, the remedy should be given at 
intervals of one week or less, in such amount that 
no symptoms reappear. A fall of temperature or 
an- appearance of slight edema should warn the 
physician that the dose is too small, the interval 
too long, or both dose and interval should. be 
changed. If the dry extract is employed, the 
source of the powder should be known as well as 
THYROID TREATMENT 
its strength. Six to 15 grains may represent one 
thyroid gland, depending upon the manufacturer; 
tablets are unreliable, since they may not dissolve; 
capsules are uncertain on account of the varying 
solubility of the gelatin, and on no account should 
the powder be previously made into a mass. As a 
rule, the powder should be used as such, and in 
about double the dose by mouth as when injected 
subcutaneously. The glycerin extract is more 
useful; but of each specimen the dose must be 
determined clinically, since accurate standardiza- 
tion is, at present, impossible. 
Cretinsim or Infantile Myxedema.-The same 
rules apply and the same results are obtained- 
the dose being somewhat larger than reached by 
Young's rule and determined by experiment. 
Here the increase of height is notable, and the 
development of the intellectual processes is a 
fairly accurate index of the success of the treat- 
ment. In children the difficulties are fewer and 
the dangers less, for toxic symptoms are but rarely 
observed. 
The treatment of postoperative myxedema (after 
total extirpation of the thyroid) yields brilliant 
results when used as a prophylactic. In compari- 
son with the small number of patients observed, the 
instances of toxic symptoms have been considera- 
ble in number. These are entirely unnecessary 
and would never be seen were the treatment 
always intrusted to a careful physician. The 
smallest dose at the longest interval which will 
keep the patient free from symptoms of the 
disease should be chosen. Hard and fast rules 
cannot be formulated; each patient should be 
studied. 
Obesity.-Next to the three conditions just 
enumerated, obesity affords the best example of 
therapeutic efficiency. Since the increased nitro- 
gen elimination is due to the breaking down of the 
circulating proteids and the fixed are not attacked 
until the store of fat is considerably reduced, the 
diet should not be much restricted, and nitrogen- 
ous matter ought to be well represented. In these 
cases more than ordinary care must be exercised, 
because the heart may have undergone fatty 
changes. Since heredity and habits of life have 
much to do with obesity, the results of thyroid 
administration are not always satisfactory. It is 
claimed that iodothyrin is more efficient in anemic 
obese persons than in vigorous subjects. 
The insanity of myxedema (acute or chronic 
mania, melancholia, or dementia) is amenable to 
treatment, because the disease itself can be cured. 
The insanities from other causes do not present 
constant results. In the chronic varieties the 
improvement in nutrition is likely to benefit the 
mental condition. In acute mania, by increasing 
tissue metabolism, the danger of exhaustion is 
heightened. The dangers as to the heart, gastric 
irritation, and muscular weakness must be borne 
in mind. Experience only can determine, outside 
of the exceptions noted, whether a particular 
patient will be likely to receive benefit. 
The results in exophthalmic goiter have been 
various. From the literature as well as from 
personal experience no final conclusions can be TIBIA 
TINEA VERSICOLOR 
reached. Since, as Gley very properly observes, 
the majority of the symptoms in many patients 
can be as plausibly explained by the hypothesis 
of partially deficient thyroid activity as by the 
hypothesis of augmentation of thyroid function, 
those who accept the first view are justified in 
making use of this remedy. Beyond the fact that 
it may increase the tachycardia and dangerously 
depress the heart, there is no objection to a trial 
being made-although good authority holds it to 
be contraindicated. In goiter the question de- 
pends entirely on how far the particular variety of 
disease has interfered with the proper functionat- 
ing of the gland. The only constant result has 
been that the size of the goiter is reduced by its 
administration. 
Skin-diseases.-The rapid and marked changes 
that occur in the skin of a patient suffering from 
myxedema while under thyroid treatment suggest 
its use in various dermatoses. Psoriasis and 
eczema, particularly the chronic varieties, have 
received considerable attention. At present, while 
some successes have been recorded, there is no rule 
that determines the probability of success, and 
even the treatment may aggravate the disease. 
In lupus Bramwell found more encouragement. 
The cutaneous lesions of malignant syphilis were 
markedly benefited, in the experience of Menzies, 
by thyroid medication. Various other conditions 
have been, with more or less reason, treated by 
the administration of thyroid preparations. The 
physician, bearing in mind the physiologic action 
of these, can determine the probability of success. 
The influence of the thyroid upon nutrition is 
available in the treatment of ununited fractures. 
Allusion must be made to observed facts bearing 
upon the supplemental secretion of one gland in the 
deficient action of another. In akromegaly it is 
highly probable the impaired or abolished func- 
tions of the pituitary body are taken up by the 
thyroid gland, and that with the exhaustion of 
that gland symptoms of myxedema may supervene. 
To some extent, then, the symptoms of akro- 
megaly may remain in abeyance during the period 
of exaggerated activity of the thyroid. Further, 
improvement in some respects has followed the use 
of thyroid preparations in akromegaly. Whether 
this supplementary action is reciprocal or not, so 
far as is known no recorded facts are at hand upon 
which to base an opinion. Within the boundaries 
now accurately delineated thyroid preparations 
have their use, based upon sound physiology and 
pathology; if their use is improper, the theories 
in regard to the disease are at fault, and not the 
facts now well ascertained. See Organotherapy; 
Serumtherapy. 
TIBIA.-See Leg. 
TIC. See Convulsions. 
TIC DOULOUREUX (Prosopalgia). See 
Neuralgia. 
TICK.-See Bites and Stings. 
TICK FEVER.-An obscure tropical disease 
prevalent in certain districts of Africa transmitted 
by several varieties of ticks or w'ood-lice. It is 
closely similar to, and upon further investigation 
may be proved identical with relapsing fever 
(q. v.) due to the spirillum Obermeieri. About a 
week after the bite the disease is ushered in with 
prostration, headache, pain in the back and legs, 
anorexia, vomiting, diarrhea, fever ranging from 
101° to 104° F. There may be splenic enlarge- 
ment. There are several febrile paroxysms of 
several days' duration occurring about every 
fortnight. 
TIGLIUM.-See Croton Oil. 
TINCTURE (Tinctura).-In pharmacy an al- 
coholic solution of the medicinal principles of a 
drug, and, excepting the tincture of iodin, of non- 
volatile bases. Tinctures are prepared by per- 
colation, maceration, solution or dilution; the 
menstrua employed being chiefly alcohol, diluted 
alcohol, and alcohol and water in various propor- 
tions. Two ammoniated tinctures are made 
with aromatic spirit of ammonia, in one acetic 
acid is an ingredient of the menstruum, and several 
have glycerin. The official tinctures are now 
practically in two classes as to strength, 10 percent 
for the more powerful ones, and 20 percent for the 
others, with a few exceptions. They number 63, 
the figures placed after each giving the number of 
grams of the drug in each 100 c.c. of the tincture: 
Tinctura aconiti 10, T. aloes 10, T. aloes et myrrh® 
10, T. arnic® 20, T. asafetid® 20, T. aurahtii 
amari 20, T. aurantii dulcis 50, T. belladoira® foli- 
orum 10, T. benzoini 20, T. benzoini composita 10, 
T. calendulae 20, T. calumbae 20, T. cannabis 
indicae 10, T. cantharidis 10, T. capsici 10, T. 
cardamomi 10, T. cardamomi composita 2 1/2, T. 
cimicifugae 20, T. cinchonae 20, T. cinchonas com- 
posita 10, T. cinnamomi 20, T. colchici seminis 10, 
T. digitalis 10, T. ferri chloridi 13 1/4, T. gall® 20, 
T. gambir composita 50, T. gelsemii 10, T. gen- 
tin® composita 10, T. guaiaci 20, T. guaiaci 
ammoniata 20, T. hydrastis 20, T. hyoscyami 10, 
T. iodi 7, T. ipecacuahnae et opii 10, T. kino 5, T. 
krameriae 20, T. lactucarii 50, T. lavandulae com- 
posita 0.8, T. limonis corticis 50, T. lobeliae 10, T. 
moschi 5, T. myrrhae 20, T. nucis vomicae 2, T. 
opii 10, T. opii camphorata 0.4, T. opii deodorati 
10, T. physostigmatis 10, T. pyrethri 20, T. quassiae 
20, T. quillajae 20, T. rhei 20, T. rhei aromatica 20, 
T. sanguinariae 10, T. scillae 10, T. serpentariae 20, 
T. stramonii 10, T. strophanthi 10, T. tolutana 20, 
T. Valerianae 20, T. valerianae ammoniata 20, T. 
vanillae 10, T. veratri 10, T. zingiberis 20. 
For tinctures of fresh herbs (Tinctura Herbarum 
Recentium), the pharmacopeia prescribes a gen- 
eral formula, according to which, when not other- 
wise directed, they are to be prepared by macerat- 
ing 50 grams of the fresh herb, bruised or crushed, 
in 100 c.c. of alcohol, for 14 days, then expressing 
the Equid and filtering. 
TINEA.-See Ringworm. 
TINEA VERSICOLOR (Pityriasis Versicolor, 
Chromophytosis).-A vegetable parasitic disease, 
due to the microsporon furfur, characterized by 
furfuraceous, yellowish, macular patches,occurring 
chiefly upon the trunk. 
Symptoms.-The disease begins by the appear- 
ance of yellowish macules, from the size of a pin's- 
head to that of a pea, scattered over the affected 
region. These, in the course of a few weeks or TINNITUS AURIUM 
TONGUE, DISEASES 
months, increase in size and coalesce, with the 
production of large patches. The patches are 
irregular in shape with sharply defined edges. 
The color is usually fawn, although it may vary 
from a pale yellow to a brown; occasionally it 
has a distinct pinkish tint. The affected area is 
covered by a fine, furfuraceous, mealy scaling. 
When this is not apparent, it may be made evi- 
dent by scratching the surface with the finger-nail. 
The eruption is usually confined to the trunk, 
particularly the chest and interscapular region. 
The neck, axilla, arm, and in rare cases the face, 
may also become involved. Itching of a mild 
character is usually present. 
Tinea versicolor pursues a chronic course, 
lasting, untreated, for months and years. The 
disease, with rare exceptions, is confined to adults. 
It is but slightly contagious. 
Etiology.-The disease is due to the presence 
and growth in the skin of the microsporon furfur. 
Pathology.-The corneous layer is permeated 
with a luxuriant growth of mycelium and spores. 
The mycelium consists of short, jointed, and 
angular threads, which may be clear or con- 
tain spores. The spores are rounded, highly re- 
fractive bodies, varying in size from 9/100 to 3/100 
of an inch in diameter. In tinea versicolor there 
is a characteristic tendency of the spores to become 
aggregated in masses. 
Diagnosis.-Tinea versicolor may easily be dis- 
tinguished from chloasma, vitiligo, and the macular 
syphiloderm by attention to the character and dis- 
tribution of the eruption. In doubtful cases the 
microscope will decide the question. 
Prognosis.-The disease responds promptly to 
treatment. Relapses are not infrequent. 
Treatment.-The treatment is rapidly efficient, a 
few weeks sufficing in most cases to establish a 
cure. 
1$. Precipitated sulphur, 5 j 
Salicylic acid, gr. xx 
Benzoinated lard, 5 j. 
Rub in twice a day. 
Solutions of hyposulphite of sodium (1 dram to 
1 ounce) and bichlorid of mercury (1 to 4 grains 
to 1 ounce) are easy of application and eminently 
useful. 
It is well to continue the treatment for some 
time after apparent cure in order to preclude the 
possibility of relapse. 
TINNITUS AURIUM.-The subjective ringing, 
roaring, or hissing sound heard in the ears in 
various affections of the tympanum and internal 
ear, and also after the administration of certain 
drugs in large doses, notably quinin. 
It may be continuous or intermittent, of all 
characters, and localized in the ear or extending 
over the cranium. Tinnitus is a frequent symptom 
of disease of the external, middle, or internal ear. 
It is usually present when there is undue pressure 
on the labyrinth. Cerumen on the tympanic 
membrane, imperfect entrance of air into the 
tympanum from obstruction of the caliber of the 
Eustachian tube, or effusion into the tympanic 
cavity will cause it. It follows blows on the head, 
and is a prominent symptom in all nervous affec- 
tions of the auditory apparatus. An altered con- 
dition of the blood-vessels, anemia, cerebral con- 
gestion, large doses of quinin, deranged digestion, 
and diseases of central origin, are causes. It 
occurs as a prelude to epileptic attacks, syncope, or 
vertigo, and is not uncommon in the gouty or uric 
acid diathesis. 
Treatment.-Any curable local condition should 
be treated, and the general health improved. The 
tinnitus in nervous affections is very intractable. 
The most useful tonic is strychnin, while quinin 
exerts a distinctly injurious effect, particularly in 
large doses. See Ear (Diseases). 
TITUBATION.-The staggering gait and inco- 
ordination of motion accompanying certain diseases 
of the spine and cerebellum; also the staggering 
gait of the drunkard. 
TOBACCO (Tabacum).-The dried leaves of 
Nicotiana tabacum, native to America. Its 
properties are mainly due to an alkaloid, nicotin, 
c10h14n2, which, next to prussic acid, is the most 
rapidly fatal poison known. Tobacco is but rarely 
used in medicine; but it is a powerful depressant, 
nauseant, emetic, diaphoretic, and antispasmodic; 
it is also narcotic and sedative, lowering arterial 
tension. In toxic doses death occurs by paralysis 
of the respiratory centers. It is used chiefly as an 
antispasmodic, and is said to be effectual in tetanus. 
T. Enema, 20 grains in 8 ounces of hot water for 
each enema. T., 01., obtained by distillation; 
violently poisonous. T., Vinum, 1 ounce to 1 pint. 
Dose, 5 minims to 1 dram. Nicotin, the alkaloid, 
efficient in tetanus and strychnin poisoning. Dose, 
1/20 to 1/10 minim and up to 2 minims in 2 hours. 
Preparations unof. See Lambert Treatment for 
Narcotic Addiction. 
TOE, Amputation.-See Foot (Amputation). 
TOLU.-See Balsam. 
TONGUE, DISEASES.-Tongue-tie is due to the 
tongue being more or less tightly bound down to 
the floor of the mouth by the shortness of the 
frenulum. It is likely, when well marked, to inter- 
fere with sucking, and later, with distinct speech. 
It is easily remedied by dividing the frenulum with 
probe-pointed scissors, care being taken to direct 
the points downward and backward and merely 
to notch the free border, lest the ranine artery be 
wounded-an accident that, in infants, has been 
attended by severe and, in some cases, fatal hemor- 
rhage. If the division of the frenulum is too free, 
the tongue may loll backward, pressing the 
epiglottis over the entrance of the larynx, and 
produce severe dyspnea or even fatal asphyxia- 
"swallowing the tongue," as it has been called. 
On drawing the tongue forward the symptoms will 
at once cease; but a ligature should be passed 
through its tip and secured to the cheek, with in- 
structions to again draw the tongue forward with 
ligature should the symptoms recur. 
Macroglossia, or hypertrophy of the tongue, 
may be congenital or acquired. In either case 
it is rare. 
Causes.-The affection appears to be due to 
occlusion of the lymphatics at the base of the 
tongue; at any rate, the lymphatics are found TONGUE, DISEASES 
TONGUE, DISEASES 
enlarged and distended with lymph, and the 
connective tissue is increased in amount and 
infiltrated with lymphoid corpuscles. It appears 
related, therefore, to elephantiasis-a condition 
sometimes found coexisting in the neck and other 
parts of the body. 
Symptoms.-The whole tongue is uniformly 
enlarged, and sometimes so much so that it 
presses forward the alveolar process of the lower 
jaw with the incisor teeth, and protrudes from the 
mouth, hanging as low as the chin. When thus 
exposed, the mucous membrane becomes cracked, 
spongy, and bluish-red, and is subject to repeated 
attacks of subacute glossitis. 
The treatment is excision of part of the organ. 
The removal of a V-shaped piece has been attend- 
ed by excellent results.. It should be done before 
the teeth and jaw have been deformed by the 
pressure. 
Acute parenchymatous glossitis, or deep in- 
flammation of the tongue, may be due to mercury, 
fever, iodism, injury, carious teeth, stings of 
insects, abscesses beneath the jaw; sometimes 
there is no apparent cause. 
Symptoms.-In severe cases the whole tongue 
is swollen, and protrudes from the mouth, inter- 
fering with speech and deglutition, and sometimes 
threatening suffocation. It frequently ends in 
abscess. It is often attended with high fever and 
salivation, and may be quite sudden in its onset. 
Treatment.-Should a brisk purge and the 
milder measures applicable to acute inflammations 
fail, free longitudinal incisions, which need not be 
deep, should be made along the dorsum of the 
tongue, and the swelling will usually subside in a 
few hours. 
Suppuration and abscess sometimes follow an 
attack of acute glossitis; but the preceding 
inflammation may be so slight as to be over- 
looked. The abscess, which then forms a firm, 
tense, elastic swelling in the substance of the 
tongue, may be mistaken for a gumma or car- 
cinoma; but the diagnosis is readily made by an 
exploratory puncture. A free incision is the 
proper treatment, the cavity filling up in a few days. 
Chronic superficial glossitis (leukoplakia buc- 
calis), also known as psoriasis, or ichthyosis of 
the tongue, or smokers' patches, is a chronic 
inflammation of the mucous membrane, and may 
be induced by syphilis, excessive smoking, some 
forms of dyspepsia, the abuse of spirits, jagged 
teeth, etc. It may be found associated with 
psoriasis. The mercurial treatment of syphilis 
may be a factor in its etiology. The disease has a 
marked tendency to become malignant. 
Treatment.-All sources of irritation, especially 
smoking, stimulants, and condiments, should 
be avoided; antisyphilitic remedies should be 
given when indicated; gastritis, if present, should 
be treated; and soothing washes of chlorate of 
potassium, or sodium bicarbonate (20 grains to 
the ounce) should be applied. Should any of the 
leukoplakial patches show signs of ulceration, the 
whole patch should be excised at once; or should 
signs of epithelioma already be present, the whole 
or half of the tongue should be removed. 
Simple ulceration may depend on digestive 
disturbance (dyspeptic ulcer) or on irritation, as 
of a sharp or carious tooth, hot pipe-stem, etc. 
(dental or irritable ulcer). Both varieties are 
generally superficial, and unattended by the 
induration and infiltration characteristic of epithe- 
lioma. The dyspeptic ulcer usually occurs on 
the dorsum of the tongue near the tip. The 
ulceration is sometimes extensive and multiple, 
and is often accompanied by some superficial 
glossitis at other parts of the tongue. The 
dental ulcer is situated on the side of the tongue, 
and generally corresponds with a carious or sharp 
tooth. At first it may be a mere superficial, red 
abrasion, but if neglected, it becomes a distinct 
ulcer, irregular in shape, and surrounded by an 
inflammatory area. The edges are abrupt and a 
little raised, but not everted; the base is depressed, 
sloughing, and sometimes phagadenic, but not 
indurated unless the ulcer has existed some time, 
when it may become callous. It is always un- 
attended by infiltration. 
Treatment.-In the dyspeptic ulcer the diet and 
bowels must be carefully regulated, bismuth or 
sodium in infusion of calumba given internally, 
and soothing washes or borax and honey applied 
locally. Caustics must be avoided. In the 
dental ulcer any offending tooth must be filed, 
stopped, scraped, or extracted; in short, every 
source of irritation removed. The ulcer will 
then heal rapidly, but if neglected, it may be- 
come epitheliomatous. On the first appear- 
ance of infiltration, therefore, free excision is 
imperative. 
Tubercular ulceration of the tongue is rare, and 
generally occurs in young adult males, the sub- 
jects of phthisis or of general tuberculosis. It 
usually begins as a small pimple or nodule on the 
dorsum of the tongue, especially near the tip. 
This, after a short time, breaks down into round, 
oval or irregular, painful ulcer. The edges are 
slightly raised, vertical, inverted, or undermined, 
sometimes slightly thickened, but never everted 
or greatly indurated. The base is uneven or 
nodular, and covered with coarse, pinkish-gray 
granulations, or with a gray or yellow shredded 
slough. Sometimes several smaller ulcers appear 
around the one first formed, and coalesce with 
it. The ulceration usually progresses in spite of 
treatment, the patient dying of phthisis or other 
tubercular affection. The absence of glandular 
enlargement, of induration, and of signs of syphilis, 
along with the presence of tubercle elsewhere, and 
the characters enumerated, should serve to distin- 
guish it from syphilitic and epitheliomatous 
ulceration. 
Treatment has hitherto been of little avail. 
The ulcer, however, may be soothed by Ferrier's 
snuff or cocain; or if the constitutional state does 
not forbid, it may be scraped with a Volkmann's 
spoon, and dusted with iodoform, cauterized with 
nitrate of silver, or cut out. The usual constitu- 
tional treatment for tubercle should, of course, at 
the same time be employed. 
Syphilitic ulceration may be divided for practical 
purposes into the superficial and deep, the former TONGUE, DISEASES 
TONGUE, EXCISION 
commonly occurring in the early, the latter in the 
later, stages of syphilis. 
Treatment.-Large doses of iodid of potassium, 
combined with quinin, if the constitution is at all 
broken, and the local application of a cleansing 
gargle, as chlorate of potassium, will rapidly cause 
them to heal. The scars left by these ulcers 
sometimes, though rarely, degenerate into epithe- 
lioma. Should any induration, therefore, appear 
in them, their free removal with the knife should 
at once be undertaken. 
Epitheliomatous ulceration is due to the break- 
ing down of squamous carcinoma. It is described 
under ulceration instead of among new growths, 
as, in consequence of the irritation from the 
teeth and the movements of the tongue, epithe- 
lioma in this situation very rapidly ulcerates, 
even if it does not begin as an ulcer; hence, it is 
from other ulcers rather than from new growths 
that it has to be distinguished. It is much more 
common in men than in women, and seldom 
occurs under the age of 40. Often it is due to 
some form of irritation such as that produced by 
a carious or sharp tooth, or a syphilitic ulcer, or 
leukoplakia. Occasionally it begins as a wart 
or pimple in patients in whom no cause for it can 
be assigned. It is most common on the side of 
the tongue opposite the molar or bicuspid teeth. 
The ulcer is irregular, with raised, sinuous, hard, 
and everted edges, and uneven, excavated, or 
warty base; while the tissues around are infiltrated 
and indurated. Its growth is generally rapid, 
and attended with neuralgic pain and copious 
salivation. If allowed to take its course, it 
spreads backward to the pillars of the fauces, 
downward to the floor of the mouth, and inward 
to the opposite half of the tongue; while the sub- 
maxillary lymphatic glands, and later the lym- 
phatic glands in the neck, become enlarged, and 
the parts about the angle'of the jaw infiltrated and 
matted together by the disease. Secondary 
ulcers then form from the breaking down of the 
glands in the neck, and the patient dies, worn out 
by pain and irritation, or exhausted by hemor- 
rhage; but, like squamous carcinoma in other 
parts, it seldom becomes disseminated in distant 
organs. 
Treatment.-Early and free extirpation ought, 
in every instance, to be undertaken, but even then 
a recurrence in the glands of the neck is only too 
frequent. When the disease has attained some 
magnitude, the propriety of removal becomes a 
question, and opinions differ as to under what 
circumstances it ought to be attempted. Its 
removal is contraindicated: (1) When it has ex- 
tended so far backward that the finger cannot 
reach healthy tissue beyond it; (2) when it is 
firmly and extensively adherent to the jaw; (3) 
when the tongue is firmly bound down to the floor 
of the mouth; (4) when the glands not only below 
the jaw, but deep in the neck, are much im- 
plicated; and (5) when the patient is too weak or 
emaciated from the disease itself, or from disease 
of other organs, to withstand an operation. 
Moderate enlargement of the glands, slight ad- 
hesion to the jaw, and some infiltration of the floor 
of the mouth, do not, it is thought, forbid an 
operation (especially if the patient is suffering 
from much pain, and is otherwise in good health), 
provided the whole of the disease with the enlarged 
glands can be removed. When the disease is 
regarded as beyond the reach of extirpation, the 
pain and salivation may often be relieved by 
removing not only decayed, but sound, teeth 
that may be irritating the growth, or by stretching 
or dividing the gustatory nerve. This, which, 
however, is sometimes impracticable on account 
of the extension of the growth, may be done by 
making a small incision transversely from the 
last molar tooth through the mucous membrane 
to the side of the tongue, then passing an aneurysm 
needle into the wound, and hooking up the nerve, 
which is here quite superficial. Cocain, or morphin 
and glycerin, may be painted on the part, while 
the patient's remaining span of life may be 
rendered bearable by increasing doses of opium 
or morphin (Walsham). 
Tumors of the Tongue.-Papillomatous or 
warty growths are not uncommon, and may be 
distinguished from epithelioma, into which they 
are liable to degenerate as age advances, by the 
absence of induration about their base. They 
should be freely removed by the knife or scissors. 
Vascular tumors or naevi and lymphangiomata are 
occasionally met with, and may be destroyed by 
the ligature or knife. Fibrous, fatty, myxomatous, 
adenomatous, sarcomatous, and carcinomatous tumors 
other than the squamous variety, which has already 
been described under epitheliomatous ulcera- 
tion, are too rare in the tongue to call for further 
remark. 
Syphilis of the Tongue.-Primary chancres, 
which are very rare in this situation, require no 
description. Mucous tubercles consist, as else- 
where, of heapings up of epithelium over infiltrated 
and enlarged papillae, and appear as flattened 
elevations of a grayish-white color. They are 
generally present on the palate and fauces at the 
same time. Mercury internally, and black wash 
locally, cause them rapidly to disappear. Super- 
ficial glossitis and the superficial and deep ulcera- 
tions have already been described. Gumma occurs 
as a hard, globular mass in the fibrous tissue of 
the septum, and also in the substance of the 
muscles. It may be single or multiple. The 
mucous membrane covering it is at first natural 
in appearance, but as the gumma softens, it gives 
way, and a deep syphilitic ulcer is produced, 
lodid of potassium is the remedy. 
See Hypoglosal Nerve. 
TONGUE, EXCISION. Excision with the knife, 
on account of the profuse hemorrhage that attends 
it, is only applicable when the anterior portion 
of the tongue requires removal. The tongue 
should be well drawn forward, and the dis- 
eased portion cut away with one sweep of the 
knife, and the bleeding vessels tied. 
The ecraseur is much less used than formerly. 
The mouth having been widely opened by a gag, 
two ligatures are passed through the tongue, 
one on either side of the tip, and the mucous mem- 
brane, where it is reflected from the tongue to the TONGUE, EXCISION 
TONGUE, EXCISION 
jaw, is divided with scissors along with some of 
the fibers of the geniohyoglossus. The mucous 
membrane covering the dorsum of the tongue is 
next divided in the middle line by a bistoury, 
from the tip as far back as to be well beyond 
the disease. This allows the tongue to be readily 
split with the fingers into two halves. The cord 
of the dcraseur is now passed over one-half, 
and well behind the disease, and, if the whole 
tongue is to be removed the cord of a second 
6craseur over the other half. The cord being 
tightened by screwing up the ^craseur, the tongue 
is cut through. The lingual artery, with the gusta- 
tory nerve, is drawn out in the form of a loop by 
the cord of the 6craseur. A ligature should be 
passed around the artery with an aneurysm 
needle, and the artery severed in front of the 
ligature. The anterior part of the tongue will 
now come away, leaving the ligature on the artery 
in the stump of the tongue. 
Excision with the scissors (Whitehead's method) 
consists in drawing the tongue well forward by 
two ligatures through its tip, dividing the frenulum, 
splitting the tongue as previously described, and 
then separating the diseased half from its attach- 
ments, beginning from below by a series of short 
snips with blunt-pointed scissors, clamping or tying 
the lingual artery, if seen, before it is divided, 
or else immediately after it is cut. The lingual 
artery lies immediately below the muscle substance 
about 1/4 inch from the middle line. If the 
disease involves both sides of the tongue, the 
opposite half can next be removed in the same 
way. Should bleeding occur, it can always be 
arrested temporarily by merely passing the finger 
into the pharynx and pressing the tongue against 
the inner surface of the jaw, and then as soon as the 
mouth has been sponged clear of blood, the bleed- 
ing vessel can be seized and tied. Or Lockwood's 
clamp for compressing the lingual artery may be 
used during the operation if the surgeon fears 
severe hemorrhage, the only objection to it being 
that it is likely to get a little in the operator's 
way. Some surgeons operate with the patient's 
head hanging over the end of the table, so that the 
blood may not run down into the throat. When 
Hahn's cannula is used, it is often kept in for 
several days after the operation, for the purpose of 
excluding septic discharges from the air-passages 
and so preventing septic pneumonia. The ad- 
vantages of the scissors over the ^craseur are that 
a cleaner-cut surface is left and consequently 
that the surgeon can be more certain of having 
removed the whole of the disease; that less slough- 
ing occurs; and that the operation is more quickly 
performed. When, however, the tongue is ad- 
herent to the floor of the mouth and hence cannot 
be drawn forward, or the mouth cannot be opened 
sufficiently wide, or the light is bad, or a reliable 
assistant is not at hand, removal with the scissors 
is attended with considerable difficulty, and 
under these circumstances removal with the 
6craseur will be found safer (Walsham). 
Excision with the galvanocautery is strongly 
recommended by some surgeons, but is open to 
the serious objection that it is liable to be followed 
by secondary hemorrhage on the separation of the 
sloughs. 
Kocher's Operation.-A preliminary tracheot- 
omy is performed, and an ordinary cannula in- 
serted. Entry of blood is prevented by plugging 
the pharynx with a sponge soaked in carbolic acid. 
The incision runs along the anterior border of the 
sternomastoid from the ear down to nearly the 
middle of the muscle; from this it turns forward 
to the hyoid bone and along the anterior border 
of the diagastric to the symphysis. A flap, con- 
taining skin, platysma, and fascia, is reflected 
upward; the facial artery and vein are tied; the 
lingual artery is secured on the hyoglossus; and 
the submaxillary fossa is completely cleared out, 
beginning from behind. All the cellular tissue is 
removed, together with the lymphatic glands, and 
the submaxillary and sublingual glands are re- 
moved if they appear involved. The mylohyoid 
muscle is then separated, the mucous membrane 
divided, and the tongue drawn through the open- 
ing. If the whole thickness is removed, the oppo- 
site lingual must be tied as well. 
Preliminary Treatment.-Before commencing 
the operation, the mouth and the nasal cavities 
are thoroughly washed out with a solution of 
bichlorid of mercury (1:2000); and after it is 
finished and the wound adjusted with sutures, the 
surface of the stump and the pharynx behind it are 
covered over completely with a sponge soaked with 
carbolic acid. The dressings are changed twice a 
day, advantage being taken of the opportunity to 
pass an esophageal tube and feed the patient; for 
the rest, nutrient enemata are used. The operation 
is undoubtedly more extensive than the others, but 
it is believed that this is amply compensated for 
by the thoroughness with which the whole of the 
affected tissue is removed and the way in which 
the risk of septic inflammation and pulmonary com- 
plications is avoided. Kocher himself has been 
very successful as regards immediate mortality, 
but the operation does not seem to have been 
performed by other surgeons to any great 
extent. 
The after-treatment of these cases requires even 
more than ordinary care. Every endeavor must 
be used to prevent putrefaction, which, owing to 
the temperature, moisture, and alkaline reaction, 
is very prone to follow; the patient's strength 
must be husbanded and maintained in every way; 
and precautions taken to prevent food or the dis- 
charge from the wound entering the lungs. With 
this in view, Kocher fills the entire cavity, from 
the edge of the wound back into the mouth and 
pharynx, with a sponge soaked in carbolic acid 
solution, shutting off the nasopharyngeal cavity 
on the one hand and the larynx and pharynx on 
the other. The same object may, however, be 
achieved much more satisfactorily by means of a 
plan recommended by Barker: The whole wound 
is carefully cleansed, dried, and dusted with iodo- 
form, and the two ends of the incision sutured. 
In the middle a piece of rubber tubing is adjusted, 
long enough to reach well down into the esopha- 
gus; and all the space around is carefully packed 
with antiseptic wool. This can be left untouched TONGUE IN DIAGNOSIS 
TONSILLITIS 
for days, the patient being easily fed by means of 
a funnel as often as it may be required. 
TONGUE IN DIAGNOSIS.-The tongue is a 
general index of disease, whether its condition is a 
ocal manifestation of a constitutional disturbance 
or whether the process is limited. The coated 
tongue of certain gastric disorders, the reddened 
tongue of fever, the strawberry tongue of scarla- 
tina, the brown coating and fissuring of the 
typhoid tongue, the hypertrophic and thickened 
tongue of myxedema and akromegaly, and the 
pigmented tongue of suprarenal disease are all 
characteristic. Herpes febrilis, mucous patches, 
aphthous stomatitis, and thrush often have their 
starting-point in this organ. 
The elongated and pointed tongue indicates a 
condition of irritation and determination of blood 
to the stomach and bowels. The full tongue, 
broad and thick, is evidence of atony, want of 
action in the digestive tract. The dry, pinched 
tongue expresses a want of functional activity in 
the digestive organs. It is the tongue of acute 
disease, and is usually associated with dryness. 
The fissured tongue in chronic disease indicates 
inflammatory action of the kidneys. The fissured 
tongue in advanced stages of acute disease is 
significant of lesions of the kidneys or irritation of 
the nerve-centers. In many cases there is a defect 
in the secretion of urine. 
Dryness and moisture are important evidences 
of the condition of the digestive organs. If the 
tongue is dry, the stomach and intestines are dis- 
ordered. In acute disease with dryness of the 
tongue, when it becomes moist, improvement is 
indicated, and it is nearly always looked upon as a 
favorable symptom. 
The thin, transparent coating of the tongue gives 
evidence of enfeebled digestion, frequently from 
intemperate eating and drinking. A tongue coat- 
ed heavily at the base calls attention to accumula- 
tions in the stomach, and suggests the use of an 
emetic. The broad pallid tongue gives evidence 
of a want of the alkaline elements of the blood. 
It may be the basis of the disease, which will fade 
away as soon as the proper alkali is given, or it may 
be but a portion, the alkaline salt preparing the 
way and facilitating the action of other remedies. 
The deep red tongue, generally dry, indicates an 
acid. 
TONICS.-Medicine or agents that promote 
nutrition, and give tone to the system. The most 
typical agents are strychnin, quinin, iron, and the 
vegetable bitters. Those especially acting on the 
stomach are arsenic, bismuth, cinchona, hydrastis, 
and nux vomica; on the spinal cord and general 
circulation, strychnin; on the heart, digitalis, squill, 
convallarin, and cimicifuga; on the general nervous 
system, phosphorus, quinin, and the valerates; 
on muscular tissue, tannin; on the blood, iron, 
manganese, cod-liver oil, and other fats. 
In administering tonics care is required to see 
that the tonic is suitable to the case; for in appar- 
ent debility and imperfect functional activity, 
imperfect removal of tissue or other waste is 
responsible. Not tonics, but cholagogs, purga- 
tives, etc., are then indicated. Tonics are em- 
ployed in debility of the whole or part of the body; 
the character of the medicinal agent depends upon 
the part affected. 
General tonic prescriptions: 
1$. Quinin sulphate, gr. xx 
Dried iron sulphate, gr. xl 
Strychnin sulphate, gr. ss. 
Divide into 20 pills. Give 1 pill 3 times a day. 
I). Tincture of iron 
chlorid, 
Dilute phosphor- 
ic acid, 
each, 3 ss 
Simple syrup, add enough to 
make g iij. 
A teaspoonful 3 times a day. 
1$. Arsenic trioxid, gr. j 
Strychnin sulphate, gr. 1/3 
Quinin sulphate, 3 j. 
Divide into 20 pills. One pill after each meal. 
1$. Iron sulphate, gr. xij 
Magnesium sulphate, 5 vj 
Dilute sulphuric acid, 3 j 
Infusion of quassia, g vj. 
Tablespoonful in water 3 times a day. 
I|. Solution of potassium arsen- 
ite, x 
Fluidextract of nux vomica, xx 
Compound tincture 
of gentian, 
Tincture of cin- 
chona, 
Tincture of calum- 
ba, 
Wine of kola, 
each, 3 iv. 
A tablespoonful after each meal. 
1$. Tincture of nux vomica, 3 ij 
Tincture of cinchona enough 
to make, g iv. 
A teaspoonful after each meal. 
In atonic dyspepsia: 
1$. Dilute nitrohydrochloric acid, 5 vj 
Solution of strychnin, 3 jss 
Tincture of orange, 
Tincture of calumba, 
Compound infusion of gentian, 
add enough to make g x. 
Tablespoonful in a wineglassful of water 3 
times daily, after eating. 
Or: 
I}. Strychnin sulphate, gr. j 
Dilute nitrohydrochloric acid, 5 j 
Compound tincture of gentian, g j 
Compound tincture of card- 
amom, g ij 
Solution of pepsin, add enough 
to make g iv. 
A teaspoonful after each meal. 
TONSILLITIS (Amygdalitis). Varieties.-(1) 
acute; (2) chronic; (3) phlegmonous (quinsy, ton- 
sillar abscess). 
Etiology.-(1) It most often occurs during 
each, 3 j TONSILLITIS 
TONSILLITIS 
youth or adolescence; (2) exposure to the cold and 
wet; (3) heredity; (4) certain diseases, such as 
lithemia, rheumatic diathesis; (5) changeable 
climate. 
Pathology.-In the first stage, superficial, of 
acute tonsillitis the catarrhal inflammatory proc- 
ess is principally confined to the mucous mem- 
brane of the tonsil, which is covered with a viscid 
secretion. The epithelium desquamates rapidly. 
The organ is enlarged from congestion of the blood- 
vessels. In the second stage, lacunar or follicular, 
the epithelium collects in the crypts, and under- 
goes necrosis, forming small, whitish, offensive, 
cheesy masses, which obstruct the secretion of the 
gland. In the last stage, parenchymatous, a 
phlegmon may form constituting circumtonsillar 
abscess or quinsy. 
Symptoms and Clinical Course. Acute follicular 
Tonsillitis.-The onset is generally marked by 
chilliness or a general body ache. The tempera- 
ture may rise suddenly-often to 104° F.-within 
the first 24 hours. The region of the affected part 
is dry, hot, and gives rise to severe pain on swallow- 
ing or on opening the mouth. The tonsils are 
enlarged, and may be felt externally. The sur- 
face is usually covered with a thick whitish mucus, 
often offensive. The tongue is heavily coated; 
urine high colored, scanty, and contains excess of 
urates. In the follicular stage the glands are red 
and swollen, and in the crypts are seen the small, 
whitish, cheesy plugs, which are the remains of 
degenerated epithelium. They may often be 
brushed away in making local applications, leav- 
ing small depressions in the glandular substance. 
In many cases they become detached, and are 
cast off with the expectoration. 
Chronic Tonsillitis.-The lacunae of the tonsil 
are filled with debris which impart a fetid odor to 
the breath. From time to time these cheesy 
masses are expectorated. The quality of the 
voice may be altered. There is a more or less 
constant cough. The tonsils may be slightly 
or markedly enlarged. 
Phlegmonous Tonsillitis (Quinsy).-The affected 
organ is very painful and greatly distended by the 
purulent collection, which may be throbbing in 
character. The jaws are stiff, and the mouth can- 
not be opened. Often the pain is diffused over 
the whole angle of the jaw. The jaws may be 
edematous, and fluctuation may be obtained on 
palpation of the parts. 
Deglutition is painful, and often entirely lost; 
the voice becomes hoarse, and has a nasal charac- 
ter; saliva is greatly increased. The fever is 
higher, as a rule, and the suffering more intense 
than in the other varieties of tonsillitis. 
Diagnosis.- 
Tonsillitis. 
Diphtheria. 
Scarlet Fever. 
2. Onset sudden ; 
2. Onset gradual. 
2. Onset sudden; 
high fever rising 
Urine quickly 
strawberry 
rapidly. 
showing albu- 
min and casts. 
tongue; scarlet 
red rash; pulse 
rapid, out of pro- 
portion to tem- 
perature; con- 
vulsions frequent. 
3 Severe pain in 
3. General body 
3. Prostration se- 
region of tonsil on 
opening the mouth; 
moderate prostra- 
tion. 
pain as well as 
pain in angle of 
jaws; severe 
cough or bron- 
chitis may be 
present; pros- 
tration severe. 
vere. 
4. Absence of mem- 
4. Grayish-white 
4. False membrane 
brane in all forms; 
membrane, and 
may be present, 
small cheesy lumps 
on being pulled 
but absence of 
in the crypts of 
off leaves be- 
Klebs - Loeffler 
gland in follicular 
tonsillitis. 
hind a bleeding 
surface; mem- 
brane contains 
K1 e b s-Loeffler 
bacilli. 
bacilli. 
5. No sequels; symp- 
5. Paralysis of 
5. Tendency to 
toms subside 
quickly. 
nerves of phar- 
ynx or eye com- 
mon. 
nephritis. 
Prognosis is favorable, except in the phlegmon- 
ous form, which may involve the deeper tissues, 
and extend downward behind the carotid sheath, 
causing death. 
Treatment of Acute Follicular Tonsillitis.-In 
the majority of cases it is well to begin the treat- 
ment by the administration of calomel in frac- 
tional doses, or saline purgatives. Should there 
be a rheumatic diathesis, sodium salicylate, or 
preferably aspirin, 7 grains every 3 or 4 hours, 
should be given. If temperature is high (102.5° 
F.), phenacetin, 5 grains every 4 hours, and quinin, 
4 grains, maybe given from the onset of the symp- 
toms. 
1$. Tincture of aconite, xl 
Elixir curacoa, 5 iij 
Solution of potassium citrate, 
add enough to make 3 iij. 
Tablespoonful every 3 or 4 hours. 
Guaiac may be given in the form of the com 
pound tincture, 1 dram with milk every 4 hours, 
or may be used as a gargle. It may also be admin- 
istered in the form of a lozenge: 
1$. Guaiac, 3 v 
Oil of lemon, tt[ x 
Oil of peppermint, nt iv 
Acacia, 3 ss 
Sugar, 3 jss. 
Confection of rose, add enough to make 
30 lozenges. 
Allow 1 to dissolve in the mouth every 3 or 
4 hours. 
Local Treatment.-Small pellets of ice may be 
allowed to dissolve in the mouth to relieve the 
inflammation. If the application of cold is dis- 
agreeable, hot compresses may be substituted. 
Occasionally, spraying through the anterior nares 
Tonsillitis. 
Diphtheria. 
Scarlet Fever. 
1. History of expo- 
sure to cold and 
wet; rheumatic 
diathesis, or his- 
tory of previous 
attack. 
1. History of con- 
tagion. 
1. History of con- 
tagion. TONSILS, HYPERTROPHY 
TOOTHACHE 
with an alkaline solution (see Pharyngitis) will 
prevent mouth-breathing, and relieve the catarrhal 
process often present in these parts. 
Local applications of nuclein solution (5 percent) 
twice daily, and also internally in doses of 1 tea- 
spoonful every 4 hours, are valuable. Bicarbon- 
ate of sodium or aspirin 
applied locally may afford 
marked relief. 
Treatment of Chronic 
Tonsillitis.-If the tonsils 
are not enlarged the crypts 
should be emptied by the 
curette and obliterated by 
some caustic such as silver 
nitrate or preferably by 
the galvano-cautery. If 
the tonsil is enlarged it 
should be removed with the 
snare or guillotine. If this 
is not permitted, daily garg- 
ling with antiseptic solu- 
tions should be insisted upon and applications 
of strong tincture of iodin or trichloracetic acid 
should be made to the crypts. Daily cold bathing 
especially of the neck, is excellent. It is important 
to pay attention to the general health in regard to 
food, exercise, clothing, and tonics. 
Treatment of Phlegmonous Tonsillitis.-Hot 
applications should be applied to the angles of the 
jaw; at the earliest possible moment, the abscess 
should be opened with a sharp pointed (but 
guarded) tenotome, the incision being parallel with 
the anterior pillar of the fauces, and directed 
toward the middle line. In all cases the diet 
should be light and nutritious. 
the mouth half open; regurgitaton of fluids through 
the nose; snoring during sleep; distressing dreams, 
from the imperfect aeraton of the blood; and recur- 
ring attacks of acute or subacute tonsillitis; deafness 
from implication of the eustachian tube and middle 
ear in chronic inflammation, may sometimes be 
Tonsillotome .-(Z uckerkandl.) 
induced, and even an alteration in the shape of the 
chest, and possibly phthisis. The tonsils appear 
irregularly enlarged, often almost occluding the 
fauces, but, unless inflamed, are of a natural color, 
or perhaps slightly paler than natural. 
Treatment.-In young children the affection 
may be cured by persistent painting with the tinc- 
ture of perchlorid of iron or tincture of iodin, com- 
bined with the internal use of cod-liver oil and 
syrup of the phosphate or the iodid of iron. In 
older children, or when the tonsils are much en- 
larged, they should be excised, either with the knife 
or, better, with the guillotine, and this should be 
done before the voice has become seriously affected 
or other disturbance has ensued. The hemorrhage 
attending the operation, though usually slight, 
has at times been alarming. Gargling with cold 
water will generally stop it; but if this fails, ice or 
astringents, as tannic acid, or pressure with a pencil 
guarded with lint will nearly always succeed. 
Should a bleeding vessel be seen, it should be tied 
or twisted. In exceptional cases the common 
carotid has had to be tied. Should adenoid 
growths be present, they should be removed at the 
same time as the tonsils. See Adenoid Vegeta- 
tions, Pharyngitis, Rhinitis. 
TOOTHACHE.-This is a symptom of caries, 
periostitis, exostosis, inflamed pulp, or neuralgia, 
and ultimately the patient should be sent to a 
denist. Temporary treatment, however, is often 
demanded. If there is a cavity, it should be care- 
fully cleansed with warm water and plugged with 
a pledget of absorbent cotton soaked in creosote, 
phenol, chloroform, oil of cloves, cocain, or other 
local anesthetic. A mixture such as the following 
may be used: 
1^ Cocain hydrochlorid, gr. iij 
Carbolic acid, 3 j 
Collodion, 3 j. 
A small quantity to be applied to the dried- 
out cavity upon an absorbent-cotton plug. 
Coley states that of all medicinal remedies for 
toothache none is so successful as sodium salicylate. 
TONSILS, HYPERTROPHY.-Chronic enlarge- 
ment of the tonsils is very common in strumous 
children, in whom it is frequently associated with 
adenoid growths in the vault of the pharynx. At 
times it appears due to oft-repeated attacks of 
acute tonsillitis. 
The symptoms to which it may give rise are 
a nasal tone of voice; a peculiar vacant expression, 
acquired by the child constantly breathing with 
Line of Incision in Quinsy.-(Veau.) TORMINA 
TOURNIQUET 
He believes it is especially useful in those cases 
when the pain is started by "taking cold." A 
dose of 15 grains will usually relieve the pain very 
promptly, and if this is repeated every 4 hours, the 
inflammation may entirely subside, leaving, of 
course, a carious tooth to be disposed of according 
to circumstances. The addition of belladonna is 
often advantageous. Fifteen grains of sodium salic- 
cylate with 10 minims of tincture of belladonna, 
will often procure refreshing sleep instead of a night 
of agony. It is especially valuable with children, 
when extraction of teeth is to be avoided, if pos- 
sible, lest the development of the maxilla should 
be injured. See Dental Anodynes; Dentition 
(Disorders); Teeth, etc. - - ; . 
TORMINA.-Griping pains in the abdomen. 
See Colic, Dysentery. 
TORTICOLLIS (Wry-neck).-An affection due 
to irregular contraction of the muscles, twisting 
the head. The sternomastoid is the muscle usually 
at fault-sometimes the only one-but the others 
and the cervical fascia often aggravate the evil. 
It may be primary, caused by disease of the muscle 
itself (this is usually distinguished as the con- 
genital variety); or secondary, arising from in- 
flammation of some of the structures near the 
joints, vertebrae, lymphatic glands, etc., or from 
a disordered condition of the nerve. 
Congenital torticollis is rarely noticed until some 
time after birth. This arises partly from the short- 
ness of an infant's neck, partly from the fact that the 
deformity itself is not nearly so well marked at this 
time of life as it is later. Its origin is uncertain. 
Probably it is due to partial rupture of the muscle 
at the time of parturition; at least a tender, ovoid 
mass is not infrequently found, shortly after birth, 
in the sternal head of the sternomastoid, just where 
the tendinous and musclar fibers meet; and in 
several cases wry-neck is known to have been 
present later in life. The back of the head is 
drawn down; the chin is directed toward the op- 
posite side, so that the face looks somewhat up- 
ward, and the muscle itself stands out like a tense 
cord, with a hollow in front and behind. The 
sternal portion is usually the chief offender, and 
in severe'cases the mastoid process may be dragged 
down so far as to lie immediately over and scarcely 
an inch from the sternoclavicular articulation. 
As a result, the cervical vertebrae become twisted 
and deformed; secondary curves make their ap- 
pearance in the back; the under side of the face 
does not grow in proportion to the rest; the line of 
the eyes becomes oblique; and, if the condition is 
not remedied before puberty, even the breast fails 
in its development. 
Treatment of Congenital Torticollis.-Unless the 
patient is treated by position while still an infant, 
division of the sternomastoid is generally required, 
followed by a course of systematic exercises in the 
milder cases, and the use of a supporting brace in 
the most severe. The sternomastoid is best divided 
mmediately above the clavicle, as here it is furth- 
est removed from the important structures that 
lie beneath it. A puncture should be made at the 
inner side of the tendon, a director passed behind 
it, and the division made toward the skin with a 
blunt-pointed tenotome. The tense bands of con- 
tracted cervical fascia that now start forward will 
yield to stretching; it is not safe to divide them. 
The head should be straightened, and held thus by 
a bandage and sand-bags. The puncture should be 
allowed 3 or 4 days to heal before the exercises 
are begun or the instrument is applied. Some 
advise the division of the muscle about the 
middle, believing that this is a more safe procedure; 
while others again recommend the division of the 
tendon by open incision, as in this way the danger 
of puncturing and admitting air into a vein is 
avoided. If the subcutaneous division, however, 
is carefully done in the manner here advised, there 
need be no fear of air entering the veins; sudden 
death has, however, occurred at the hands of some 
excellent surgeons, and others have met with alarm- 
ing symptoms. 
Acquired torticollis may be due to rheumatism or 
exposure to cold, or it may be symptomatic of 
inflammation of the lymphatic glands, the verte- 
brae, or other structures of the neck, the muscles 
(for in this case the splenius and others are in a 
state of tonic spasm as well) contracting to save 
the affected part. In many of these cases the 
diagnosis of the exciting cause is exceedingly 
difficult, and very great care is required, as cervical 
caries is by no means uncommon. Tonic torticollis 
of this character may always be distinguished from 
the congenital variety by its relaxing completely 
under an anesthetic, and by the absence of any 
shortening of the cervical fascia. 
Treatment of Acquired Torticollis.-In spasmodic 
cases conium, Indian hemp, bromid of potassium, 
etc., may be tried. These failing, the spinal 
accessory nerve may be stretched just above the 
spot where it enters the sternomastoid. In very 
intractable cases a piece of the nerve may be 
excised, and if the posterior cervical muscles are 
also involved in the spasm,'excision of portions of 
the posterior division of the first 4 cervical nerves 
may be simultaneously or subsequently under- 
taken. Tenotomy of' the sternomastoid should 
in these and in hysteric cases on no account be 
performed. 
TOUCH.-See Sensation (Disorders). 
TOURNIQUET.-An instrument for controlling 
the circulation by means of compression. It 
usually consists of 2 metallic plates united by a 
thumb-screw and a strap provided with a pad. 
The strap is fastened about the part, the pad being 
placed over the artery to be occluded. The screw 
is placed diametrically opposite the pad, and the 
strap is tightened by separating the metallic plates 
of the screw. Dupuytren's tourniquet is one for 
compressing the abdominal aorta, consisting of a 
semicircle of metal with a pad at one extremity. 
Esmarch's tourniquet consists of a stout, elastic- 
rubber band applied above the proximal turn of an 
elastic bandage passing around the part to be ex- 
sanguinated. It has several disadvantages: It may 
cause paralysis; it encourages sloughing, especially 
if used to check primary hemorrhage before 
amputation; oozing following its removal is often 
very great; it is intensely painful. It is better to 
apply an Esmarch bandage first. Petit's tourni- TOURNIQUET 
TRACHEOTOMY 
quet is used chiefly for the groin and the arm below 
the axilla. Its pad, or a roller about 11/2 inches 
in thickness, is placed upon the main vessel, the 
band buckled closely to the limb, and the screw 
In emergency a tourniquet can be devised from a 
handkerchief tied around a limb and twisted 
tightly. A stone or block or pad may be placed 
inside and on the bleeding point. 
TOWNS' TREATMENT.-See Lambert Treat- 
ment for Narcotic Addiction. 
TOXALBUMIN.-A proteid substance resem- 
bling a ferment rather than a poison. Any of 
the poisonous albuminoids that are produced or 
separated from the albumin of the tissues by the 
agency of bacteria, and entering the circulation 
constitute the cause of the general symptoms of 
infectious diseases. Toxalbumins have been ob- 
tained from cultures of a number of bacteria- 
among others from those of diphtheria, typhoid 
fever, cholera, tetanus, glanders, tuberculosis, 
anthrax, and pneumonia; likewise, also, from 
cultures of the staphylococcus pyogenes aureus, 
and the swine-plague bacillus; from those of certain 
germs found by Booker in the stools of the summer 
diarrhea of infants, and from those of two toxi- 
cogenic germs isolated by Vaughan from drinking- 
water. It is possible that poisonous albuminous 
substances are also produced by animal parasitic 
organisms. Thus Viron has isolated a toxic pro- 
teid from the fluid of hydatid cysts. 
TOXEMIA.-See Autointoxication, Gastritis 
(Toxic), Poisoning. 
TOXICOLOGY.-See Poisoning. 
TRACHEA, INJURIES.-See Neck (Injuries). 
TRACHELORRHAPHY.-See Cervix Uteri 
(Laceration). 
TRACHEOTOMY.-Tracheotomy is frequently 
required. It may be performed for the relief of 
obstruction, whether it is temporary (as in croup, 
diphtheria, edema of the glottis, or muscular 
spasm) or permanent (as in syphilitic stenosis); 
for the removal of foreign bodies; to give rest to the 
larynx in cases of painful ulceration; or as a pre- 
caution in operation in order to prevent the entry 
of blood. 
The trachea may be opened either above or 
below the isthmus of the thyroid; but, unless there 
is some special indication to the contrary, the 
former should always be selected. The anterior 
jugular and inferior thyroid veins are in close 
relation with the lower part. The innominate 
artery bifurcates almost on it, and sometimes 
reaches far up into the neck. The thyroidea ima 
may cross it. It lies veiy much further from the 
surface and is much more easily displaced to one 
side. In infants, too, the thymus may cause a 
certain amount of difficulty. 
The high operation, the only one that will be de- 
scribed here, may be done either with or without 
an anesthetic. Chloroform should, as a rule, 
be given to children, as otherwise their struggles 
are likely to embarrass the operator. In adults, 
however, it is not necessary as after the skin in- 
cision has been made no pain is felt, and chloro- 
form is liable to increase the dyspnea, if present, 
to a dangerous extent, and necessitates the opera- 
tion being rapidly performed; whereas the more 
deliberately it can be done, the less are the risks 
attending it. . A small pillow having been placed 
beneath the neck as so to render it prominent^ 
Petit's Tourniquet. 
turned so quickly as to compress the artery as soon 
as the veins and thus avoid passive congestion. 
To prevent the skin being dragged, a bandage 
around the limb is advantageous. Signorini's 
Esmarch Band. 
tourniquet has a pad at each end (one for pressure, 
the other for resistance), and is operated by a screw 
and ratchet in the middle so that the arc can be 
opened or closed at will. It is chiefly for use upon 
the femoral artery 
in the groin, the 
larger pad being 
placed beneath the 
tuberosity of the 
ischium. Lister's 
tourniquet is of 
large size, and in- 
tended for use on 
the abdominal 
aorta. It is to be 
placed on the pa- 
tient's right side, so that the vessel does not slip 
off the fourth lumbar vertebra, is to be screwed 
up only at the last moment, and then only with 
enough force to interrupt the circulation. 
Signorini's Tourniquet. TRACHEOTOMY 
TRACHEOTOMY 
make an incision from the cricoid cartilage, 
exactly in the middle line, for from 1 1 / 2 to 2 inches 
downward, according to the age of the patient, 
fatness of the neck, etc. Divide the skin and 
superficial fascia, and, having found the interval 
between the sternohyoid muscles, continue the 
incision between them, carefully avoiding any 
large veins. The isthmus of the thyroid will now 
be seen in the lower part of the wound as a bluish- 
red body, and if sufficient room does not exist 
between it and the cricoid cartilage, draw it down 
gently with a blunt hook; or if this cannot be 
done readily, notch it in the middle line or divide 
it. The drawing downward of the isthmus is 
greatly facilitated by dividing transversely on the 
cricoid the layer of fascia, which extends from the 
cricoid cartilage to the 
isthmus. By doing 
this, moreover, the 
wounding of the veins 
between the layers of 
fascia will be avoided. 
The first 2 or 3 rings 
of the trachea having 
now been fully ex- 
posed, and all arterial 
hemorrhage arrested 
by ligature or pressure 
forceps, thrust the 
sharp hook into the trachea immediately below the 
cricoid cartilage, and, steadying it in this way, divide 
the first 2 or 3 rings by thrusting in the knife with 
the back of the blade directed downward and by 
cutting toward the cricoid. Venous hemorrhage, 
except from a large vein, which, of course, should 
be tied or clamped, need not delay the opening of 
the trachea, as it depends on engorgement of the 
right side of the heart, and will disappear after 
2 or 3 inspirations through the tracheal wound. 
The wound in the trachea being held open by 
the tracheal dilator, pass the outer tube, made 
wedge-shaped by pressing it between the finger and 
thumb, into the trachea, and then immediately 
insert the inner cannula, as until this is done air 
cannot pass freely through the tube. Secure the 
tube in situ by tracheotomy tapes tied behind the 
up into the larynx, or if this does not succeed, 
by a Parker's suction-tube apparatus. The 
bivalve cannula in general use is likely, on account 
of its shape, to produce ulceration of the anterior 
wall of the trachea, on which, from its curve, it 
must necessarily impinge; it has even been 
known to perforate the wall and to enter the in- 
nominate artery. This can be prevented by the 
improved shaped cannula invented by Parker. 
Should the breathing cease during the operation, 
the treachea should still be opened, the obstructing 
membranes removed, and artificial respiration 
persevered in for some time. 
Dangers and Difficulties of the Operation.- 
When the operation can be done deliberately, 
and on a patient with a thin neck, it is attended 
with no great difficulty; but when, as is fre- 
quently the case, it must be undertaken in an 
emergency, possibly with insufficient light and 
with no skilled assistant at hand, or on a young 
child or infant with a fat neck, and must be com- 
pleted rapidly to prevent death from suffocation, 
it is perhaps one of the most trying that the sur- 
geon is called upon to perform. The dangers into 
which the inexperienced and unwary may then 
fall are the following. 
1. The hyoid bone or the thyroid cartilage may be 
mistaken for the cricoid cartilage, and the incision 
made through the thyrohyoid membrane or into 
the thyroid cartilage. This mistake could hardly 
occur except in a fat-necked child, and then only 
through carelessness in not determining the posi- 
tion of the cricoid cartilage before beginning the 
operation. 
2. The interval between the sternohyoid muscle 
may be missed, and the dissection carried to one or 
other side of the trachea. The thyroid body 
and even the carotid artery has in this way been 
wounded. To avoid such a disaster the head 
should be held perfectly straight and the incision 
made accurately in the middle line; one side of 
the wound should not be retracted more than the 
other; and the index-finger should be used from 
time to time to make sure that the dissection is 
being made over the trachea. 
3. Too short an incision may be made, and conse- 
quently be a source of embarrassment in drawing 
down the thyroid isthmus, and in defining the 
trachea before it is opened. The incision should 
never be less than 1 1/2 inches long, even in a 
child. 
4. One or more large veins may be wounded, and 
the steps of the operation be considerably im- 
peded by hemorrhage. Their walls are very 
thin; great care, therefore, is necessary to avoid 
injuring them. 
5. The knife may perforate the posterior wall 
of the trachea and enter the esophagus. Caution, 
therefore, is necessary, and some advise that the 
knife should be held, while incising the trachea, 
with the forefinger placed on one side, 1/2 of an 
inch from its point, so that it cannot penetrate 
too deeply. 
6. The knife may slip to one side instead of enter- 
ing the trachea. This can hardly happen if the 
trachea is fixed by the sharp hook and drawn 
Tracheotomy Tube. 
Parker's Tracheotomy Cannula. 
neck. When the operation is performed for 
croup or diphtheria, the tube should not, as a rule 
be inserted at once, but the wound held open by 
the dilator, and any false membrane removed by 
a feather passed both down into the trachea and TRACHEOTOMY 
TRACHEOTOMY 
well forward into the wound while being per- 
forated. 
7. The innominate vein and even the innominate 
artery have been wounded in incising the trachea 
during the performance of the low operation. The 
knife, therefore, should be introduced with the 
back of the blade toward the sternum, and the 
incision made from below upward. 
8. Blood may enter the trachea, and if allowed 
to remain there, will coagulate, and the clots 
being drawn into the bronchi and acting as plugs 
may cause suffocation. This danger should be 
guarded against by tying all bleeding vessels, and 
thoroughly exposing the trachea before incising 
it, lest there should be a vessel in front of it. 
Should only a little blood enter the trachea, it 
can be coughed up; but if the amount is large, the 
patient should be turned on-his side, and the head 
depressed, the wound of course being held open 
by retractors, to allow the blood to run out; or 
if this does not suffice, an attempt must be made 
to remove it by suction. When there is a general 
oozing of blood from the wound, the introduction 
of the tube will prevent more escaping into the 
trachea. 
9. The tracheotomy tube may be forced between 
the fascia and the front wall of the trachea; or one 
valve of the tube may be passed inside the trachea 
and the other outside. To escape these accidents, 
the incision in the trachea should be free, and its 
edges well retracted, or one edge may be held up 
by a sharp hook. To insure both valves entering 
the trachea, they should be pressed well together; 
this may be conveniently done by Sankey's 
forceps. 
10. The tube, when a membrane is present, may 
be passed between the tracheal wall and the false 
membrane, a danger that may be guarded against 
by removing the membrane before introducing the 
tube. 
11. The tube has been passed upward into the 
larynx instead of downward into the trachea. No 
excuse and, it is to be feared, no remedy is to be 
found for such gross ignorance (Walsham). 
After-treatment.-In the simplest case-chronic 
laryngeal stenosis, for instance, in which there is 
no pulmonary complication-all that is needed, 
provided the tube fits, is something to warm and 
moisten the air before it enters the lungs, and a 
dry absorbent dressing around the orifice to 
diminish the amount of discharge and lessen the 
risk of bronchopneumonia and cellulitis. The 
patient should be kept as quiet as possible in a 
semirecumbent position, and well protected from 
drafts. A bronchitis kettle may be used, but it is 
better, for a time, at least, to protect the orifice 
with a thin, flat sponge, wrung out of hot water, so 
as to filter the air thoroughly. The wound should 
be powdered with iodoform, and the flanges of the 
cannula prevented from pressing upon it by little 
pads of absorbent wool. The frequency with 
which the tube requires changing depends upon 
the amount of irritation it causes; a rubber one can 
often be introduced on a proper dilator by a second 
day. In cases such as these there is very little of 
that tenacious mucus that is so troublesome in 
croup or diphtheria. For the first few days the 
patient should be fed through the rectum; the 
movements of the trachea in swallowing are very 
painful (cocain sprayed over the wound prevents 
this to some extent), and there is great risk of 
fluid trickling down the larynx and passing by the 
side of the tube into the lungs. This may happen 
even after the cannula has been removed, if the 
larynx has not thoroughly recovered; but usually 
there is no danger after the wound has healed and 
the patient has grown accustomed to the change of 
respiration and learned how to cough. If the 
rectum becomes irritable or thirst is distressing, 
an esophageal tube should be used instead. 
Tracheotomy tubes, if worn permanently, should 
be frequently changed and carefully inspected 
from time to time. Their duration of life varies 
very much, and instances have been known of their 
breaking and of the end falling down into the 
bronchi. It is always well to protect the orifice 
with a suitable respirator. 
In diphtheria the after-treatment requires even 
greater care. The air must be warmed and 
moistened, and the cot surrounded by screens, but 
the top should be left open. The tube must be 
kept clean by means of feathers dipped in a solu- 
tion of bicarbonate of sodium or potassium, and 
if there is any membrane discovered floating in 
the trachea or larynx, it must be cleared away in 
the same manner. Parker recommends that the 
solution should be sprayed from time to time over 
the wound to prevent the viscid mucus collecting 
and drying around the orifice. The frequency with 
which the inner cannula requires changing depends 
upon the success with which this is carried out. 
At first it may need it almost every hour, but it 
must be remembered that the process is an exhaust- 
ing one, and, for a time, very alarming to a child, 
so that every endeavor must be made to keep the 
passage free without. Each cannula should have 
a double set of inner tubes, so that when one is 
removed and a feather has been passed down the 
outer to make sure it is clear, the second can be 
introduced without delay. The outer need only 
be removed once a day. To clear them they 
should be placed in allot solution of soda, and well 
scrubbed. The time the tube should be retained 
depends upon the course of the disease; but, in any 
case, the metal cannula should be replaced as soon 
as possible by a rubber one (it can usually be done 
by the third or fourth day), and this should not be 
worn longer than is absolutely necessary. Before 
discarding it an attempt must be made to educate 
the larynx again, and to reduce the amount of air 
passing through the tube, by using one that is 
perforated on the convexity or very much short- 
ened. The child, of course, must be watched night 
and day by some one who can use dilating forceps 
and replace the cannula at once if there is any real 
danger. 
Prognosis.-Care must be taken to distinguish 
between the consequences of the operation and 
those of the disease for which it is performed. 
Much depends upon the age of the patient; in an 
infant it is always serious, the structures involved 
are so small and delicate, and there is such great TRACHOMA 
TRACHOMA 
risk of pulmonary complications, independently 
of croup or diphtheria. If the lungs are already 
collapsed and partially consolidated, if the patient 
is exhausted by prolonged battling against immi- 
nent asphyxia, or if he is dying from the diptheritic 
poison, the operation can do no good, and trache- 
otomy must not be blamed for the result, for it 
may hasten the end. If it is to be of any real 
service, or if the wound is to be used not merely to 
relieve a symptom but to attack the disease by 
removing false membrane and giving the patient 
pure air-not that which has been befouled by 
passing over a poisoned surface-it must be per- 
formed while there is still a reasonable hope. See 
Laryngotomy. 
TRACHOMA (Granular Lids).-A disease of the 
conjunctiva, characterized by the unrestricted 
formation of follicles which, instead of being 
absorbed as in follicular conjunctivitis, produce 
permanent granular masses, spreading over the 
surface of the entire lid, and presenting, in extreme 
disappeared, there is little secretion, and the con- 
junctiva is no longer actively inflamed and rough, 
but is dry and dirty-white, thickened, and rolled 
into fine folds. This atrophic condition is called 
parenchymatous xerosis. The entire lid is now 
shorter from above downward, so that the lids 
when closed gape to a slight degree, and are turned 
in. The lashes are sparse and irregular, and 
trichiasis results. Running parallel to the under 
surface of the upper lid and 2 mm. from it a thick 
scar is sometimes seen. 
The subjective symptoms in the first stage are 
pain, itching and burning of the lids, lacrimation, 
photophobia, and asthenopia. Later on there is 
dimness of vision, which increases in the third 
stage. There are also the annoying symptoms 
caused by the inverted lashes. 
Cause and Distribution.-Poorly nourished and 
scrofulous persons are most frequently affected. 
Unhygienic habits and contagion in crowded dis- 
tricts are marked factors in the production of the 
disease. Trachoma is rare in mountainous regions 
and increases toward the lowlands. The peculiar 
susceptibility of some of the Continental emigrants 
is possibly due to their unsanitary habits, rather 
than to any inherent racial peculiarity of tempera- 
ment. According to Burnett and others, negroes 
are particularly immune from trachoma. 
There is unanimity of opinion as to the infec- 
tiousness of trachoma, and, although there is an in- 
clination to consider the disease as due to a special 
organism, the reports of bacteriologic investigation 
have not been harmonious. The trachoma bodies 
of Prowazek-Greeff, almost always found in the 
acute stages of trachoma and absent if the condi- 
tion is not trachoma, have apparently the best 
claim to specificity. These bodies or granules 
are found inside the cells and, when stained by 
the Giemsa method (on a blue field) resemble 
tiny red cocci, though they are considered by the 
investigators to be protozoa. They seem to group 
themselves near one margin of the cell nucleus. 
Prognosis is unfavorable. The disease continues 
for many years, and there is rarely complete re- 
covery. The dryness of the conjunctiva is very 
annoying, and by the irritation and exposure of 
the corneal epithelium, with consequent opacity, 
vision is affected. Entropion and trichiasis are 
disagreeable sequels. 
Treatment.-The patient should be informed of 
the infectious nature of the disease, and warned 
not to wipe his eyes on public towels. To the 
strumous and poorly nourished, change of envi- 
ronment and constitutional treatment are of great 
value. The conjunctival sac should be washed 
several times a day with boric acid or a weak solu- 
tion (1:8000) of mercuric chlorid. If the symptoms 
are acute, the temples should be leeched, cold 
applications instituted and atropin instilled. As 
the inflammatory symptoms subside, a 50 percent 
solution of boroglycerid in glycerin should be ap- 
plied twice daily. It may be alternated with 
glycerol of tannin or copper sulphate, or alum in 
pencil form. Prolonged application of silver 
nitrate leaves distressing scars and discolors the 
conjunctiva, and is not advised. Those who de- 
Trachoma. 
cases, the characteristic appearance of a bunch of 
grapes of a deep red color. The upper lid is 
generally first affected. When the follicles are 
abundant, the conjunctiva is destroyed. Ulcera- 
tion takes place, and the necrosed membrane is 
replaced by scar tissue. The disease is chronic, 
and progresses many years,' new nodules forming 
while others are ulcerating and cicatrizing. The 
bulbar conjunctiva is not usually involved. 
Course.-The disease begins with conjunctivitis, 
followed by follicular formation and growth of 
vascular tissue over the cornea, due to friction of 
the roughened lid, causing keratitis and conse- 
quent corneal opacity. The upper third of the 
cornea is most affected, and there is a distinct line 
of demarcation between the healthy cornea and the 
vascular tissue, which never entirely disappears. 
This condition is called pannus, and is fully con- 
sidered under diseases of the cornea. The second 
stage of trachoma is ulceration of the follicles. 
The secretion, until now slight, becomes muco- 
purulent, and the follicles, instead of being distinct, 
have a ragged appearance, and are ulcerated. 
The entire conjunctiva is congested, and the lashes 
are matted together with the secretion. After 
some months the disease passes into the third 
stage-cicatrization. The granulations have now TRAGACANTH 
TRANSFUSION 
rive good results from this salt use it with great 
care, and only after long experience. Borogly- 
cerid is more efficacious and can be given to the 
patient to drop in the eye at home during the in- 
tervals of visits to the physican's office. There is 
diversity of opinion relative to the value of pro- 
targol in this affection. Its use has not been fol- 
lowed by good results. Mercuric chlorid in solu- 
tion of 1:250 may be brushed over the everted lids. 
Operations destroying much conjunctiva defeat 
their own purpose, as the previous destruction of 
this membrane by the disease is already the cause 
of many disagreeable complications. In cases in 
which the granulations are very profuse and have 
not yet ulcerated, the disastrous sequels may be 
ance. The pallor of the face is the result of pro- 
found depression of the vascular system. The 
duration of trance may be from a few hours to 
weeks, months, or even a year. The postmortem 
examinations of persons who have died in trance 
throw no light on its nature. 
The diagnosis must be made from apoplexy, 
coma, and death. The presence of life may be 
determined (1) by the absence of any sign of de- 
composition, (2) by the normal appearance of the 
fundus of the eye as seen with the ophthalmoscope; 
and (3) by the persistence of the electric excita- 
bility of the muscles. This excitability disappears 
3 hours after death. See Coma. 
Treatment.-Food may be given by the nasal 
tube, or by enema. Warmth 
should be applied to the extrem- 
ities, and the development of 
bed-sores prevented. Strong 
faradization is the most power- 
ful cutaneous excitant. Nerve 
stimulants, such as ether or 
valerian, may be given by the bowel. Alcohol 
must be given with caution and in small quanti- 
ties. Strong-coffee enemata are often more useful. 
Recurrence of attacks may be prevented by the 
improvement of health, physical and moral. 
TRANSFUSION.-The operation of the trans- 
fusion of blood is not without dangers, and offers 
no advantages over the infusion of saline solutions 
either beneath the skin or intravenously. See, 
therefore, Infusion. The indications and modus 
operandi of transfusion are as follows: 
The indications for transfusion are certain cases 
of violent hemorrhage. 
Methods.-There are two methods of transfusion 
-(1) direct transfusion, (2) indirect transfusion. 
In the direct method blood from an animal is 
conveyed, by means of a specially devised appara- 
tus, directly from one person or one animal to that 
of another. According to the indirect method, 
the blood is first withdrawn, and afterward injected 
into the vein of another. 
The direct method is preferable, and is the one 
generally used. Aveling's apparatus is recom- 
mended. The operation as described by Wharton 
is as follows: The bulb and tube are first placed in 
a shallow basin containing warm normal saline 
solution (0.7 percent) and the bulb and tube are 
filled with this solution to displace any air that 
they contain. The person supplying the blood 
places his arm near the arm of the patient, and the 
operator exposes a prominent vein on the patient's 
arm at the bend of the elbow, opens it, and inserts 
into it one of the cannulas filled with saline solu- 
tion, with the point directed toward the body, and 
at the same time an assistant introduces the other 
cannula into a vein at the bend of the elbow of the 
one who supplies the blood. The cannulas are 
held in position by assistants, and the tube is 
quickly connected with them-the stop-cocks 
being closed before it is taken out of the saline 
solution to prevent the entrance of air; then upon 
opening the stop-cocks a direct communication is 
established between the circulation and the donor. 
By slowly compressing the bulb (at the same time 
Knapp's Roller Forceps. 
averted by expression. A favorite method con- 
sists of squeezing the granulations with roller 
forceps, but it is not advised as a routine practice. 
Tension may be relieved by splitting the external 
canthus and cutting the canthal ligament. Hyper- 
emic and soft granules must be more carefully 
handled. Massage with iodoform ointment may 
be used, and is less painful to the patient, and 
often gives good results in a very short time. 
Pannus should be treated by massage, peritomy, 
or jequirity inoculation. See Cornea (Diseases). 
Distortion of the lids must be corrected and cor- 
neal opacities treated. Constant instillations of 
glycerin or some bland oil are said to be palliative 
in xerosis. 
TRAGACANTH.-The exudation of several 
species of Astragalus. A natural mixture of gum 
arabic and bassorin. A demulcent employed 
mainly as a vehicle for resins and insoluble powders. 
It is a constituent of 7 of the 9 official troches, 
and is a better agent than acacia for making emul- 
sions of cod-liver oil. T., Mucilago, tragacanth 
6, glycerin 18, water to 100 parts. Dose, 1/2 ounce 
or more. 
TRANCE.-A form of catalepsy, characterized 
by a prolonged condition of abnormal sleep, in 
which the vital functions are reduced to a 
minimum, and from which the patients ordinarily 
cannot be aroused. The breathing is almost im- 
perceptible, and sensation is abolished. The on- 
set and awakening are both very sudden. 
Etiology.-Common trance occurs principally 
among females between 12 and 30 years of age; 
and the subjects are seldom in perfect health. 
Various hysteric manifestations are seen, and ane- 
mia often exists. Trance has been due to ex- 
hausting diseases, as typhoid fever and influenza; 
to excessive brain-work, or to mechanic obstruction 
to the circulation of the brain. 
Symptoms.-During a trance the subject is 
usually pale, the limbs are relaxed, the eyelids 
closed, and the eyeballs directed upward, deviat- 
ing, and sometimes diverging, from the middle 
line. The mental functions are in complete abey- TRAUMATIC FEVER 
TRICHINIASIS 
keeping the tube closed on the side of the donor) 
the blood is forced into the circulation of the 
patient. The wounds should be subsequently 
dressed antiseptically. 
Crile's method of arteriovenous anastomosis 
is described by Da Costa as follows: The vascular 
system of the donor is united to the vascular system 
of the recipient, intima being connected to intima. 
This is accomplished by means of a German silver 
tube. The vein of the recipient is drawn through 
the tube, is everted, and is tied into the second 
groove of the tube. 
The end of the tube with the everted vessel over 
it is passed into the vein of the recipient and fixed 
temporarily by a ligature. The left arm of each 
subject is usually employed and the radial artery 
of the donor is anastomosed to a superficial vein 
of the recipient. Every small branch over the 
artery is carefully tied in order to prevent obscura- 
tion by blood. The artery is bared for a distance 
of about 3 cm., tied distally, lightly clamped with 
a screw clamp proximally, and divided. The 
vein of the recipient is bared, clamped, and divided, 
the tube (dipped in sterile olive oil) is inserted 
into the vein, the cuff of everted vessel is formed 
over the end, and the artery is pulled over the 
tube and cuff of vein and held by a ligature tied 
into the first groove. 
Indirect Transfusion of Blood.-According to 
this method blood is withdrawn from the vein of 
the donor by venesection, and is received in a 
clean glass or porcelain vessel, which is placed in 
water at a temperature of 110° F. It is defibrin- 
ated by whipping with a bundle of straws, and is 
passed through fine linen; it is then injected by 
means of an ordinary syringe attached to a cannula 
which has been previously inserted into a vein of 
the patient. Care should be exercised to prevent 
air from being introduced with the blood. The 
apparatus devised by Allen and modified by Hun- 
ter is the one most frequently used. See Infusion. 
Auto transfusion.-The driving of the blood from 
the periphery to the center-the heart and the 
brain-in order to maintain the circulation, as in 
bandaging of the limbs in postpartum hemorrhage. 
Reciprocal transfusion is the exchange of equal 
volumes of blood between a patient suffering 
from a febrile disease and one who is convalescent 
from that disease, the blood of the latter being 
supposed to contain an antitoxin. 
TRAUMATIC FEVER.-See Aseptic Fever. 
TREMOR.-An involuntary trembling or agita- 
tion of the body or of some of its parts. Tremors 
are seen principally in the arms, head, hands, 
tongue, or facial muscles. They are coarse or fine, 
according to the amount of movement involved. 
They are passive or static when they are present 
during rest; if produced or increased by voluntary 
movements they are called movement or intention 
tremors, and are suggestive of disseminated sclero- 
sis, lead poisoning and senility. In addition 
they may be local or general, rapid or slow, regu- 
lar or irregular. 
Etiology.-Tremor is often observed as one of 
the nervous phenomena of chronic alcoholism and 
delirium tremens and is generally observed in 
acute poisoning by lead, mercury, arsenic, and in 
chronic poisoning by chloral and by opium. It is 
a symptom of paralysis agitans, invariably pres- 
ent, and appears in association with both paralysis 
and contracture, and it is found in hysteric sub- 
jects. It attacks the aged, chiefly in the arms and 
head. Simple tremor often occurs without assign- 
able cause, sometimes occurring as the result of 
emotions, such as fright. It is commonly present 
in debility, asthenic tremor, and passes off as 
strength is regained. In acute disease, such as 
typhoid fever, tremor indicates a profound toxemia. 
Diagnosis.-In order to ascertain whether the 
tremor be passive or intention, the patient is 
observed as he performs some voluntary act, such 
as drinking a glass of water-an intention tremor 
will be markedly accentuated. Any tremor of 
the extremities is exaggerated by extension. The 
tremor in disseminated sclerosis is irregular, and 
the movements are sudden and jerky and much 
increased by voluntary efforts at restraint. They 
are absent during rest, but occur upon movement. 
In paralysis agitans the tremor is regular and 
rhythmic, and, save early in the progress of the 
disease, occurs during both rest and movement. 
Senile tremor occurs at first only on movement, 
and during rest almost or entirely ceases. When 
severe, it may occur both in movement and in rest. 
It is more influenced by movement than is the 
tremor of paralysis agitans. 
The movements in senile tremor are exceed- 
ingly fine, beginning in the hands and often extend- 
ing to the muscles of the neck, causing slight move- 
ment of the head. Alcoholic tremor occurs only 
during movement, and chiefly affects the tongue, 
hands, arms, and face. Toxic tremors may also be 
seen in elderly men who are persistent smokers, 
and they may result from excessive use of tea and 
coffee, or from drug habituations. There is a 
peculiar form of tremor observed among smelters 
and others exposed to the fumes of mercury. It is 
sudden or gradual in onset, and is usually accom- 
panied by salivation. The arms are first involved, 
and then the entire muscular system. If allowed 
to go on, paralysis, mania, and idiocy may result. 
The tremor of exophthalmic goiter is similar to 
the toxic tremors. It is fine and rapid and is 
elicited by the extreme extension of the fingers. 
Fibrillary twitchings of the facial muscles may 
be induced by chronic alcoholism, paresis or 
profound neurasthenia. It occurs in other re- 
gions, as well in progressive muscular atrophy. 
See Blepharospasm. 
Closely allied to tremors are choreiform move- 
ments. See Chorea. 
Treatment.-This wall depend upon the causal 
condition. Little result from treatment can be 
expected. Nerve tonics and sedatives may be 
tried in simple and senile tremors. 
TREPHINING.-See Skull (Surgery). 
TRICHIASIS.-See Eyelids. 
TRICHINIASIS (Trichinosis).-A disease pro- 
duced by the ingestion of meat, pork, or sausage 
containing the trichina spiralis. The parasites lie 
coiled up in capsules between the muscular fibers 
of the meat. After their entrance into the human TRICHINIASIS 
TRIFACIAL NERVE, AFFECTIONS 
body their presence gives rise to nausea, vertigo, 
fever, diarrhea, prostration, stiffness and painful 
swelling of the muscles, edema of the face, and in 
some cases perspiration, insomnia, delirium, and 
death from exhaustion or some complication, as 
pneumonia. The. blood always shows an eosino- 
philia. The stages of the disease are the intestinal 
stage, migration stage, and encapsulation stage. 
The parasite is found in two forms-intestinal 
trichina, which is sexually mature, and muscle 
trichina, which is sexually immature. 
The intestinal trichina is a small, hair-like worm, 
the male measuring 1/18 inch, and the female 1/8 
of an inch in length; the head is smaller than the 
rest of the body; the tail of the male has a bilobed 
prominence, between the divisions of which the 
anal opening is placed, and from which a single 
spiculum can be protruded; the female has a blunt, 
rounded tail, the reproductive outlet being situated 
toward the anterior part of the body; the ova are 
very small, containing embryos that are produced 
viviparously at the rate of at least 100 each week 
after the entrance of the female into the intestinal 
canal. 
The muscle trichina develops its sexual appara- 
tus after it has entered the intestinal canal of the 
host. The viable embryos discharged from the 
Treatment.-The preventive treatment consists 
in eating no pork that has not been so prepared as 
to kill any trichinae that might exist. If the 
parasites have been recently taken-within the 
first 4 or 5 days-emetics and purgatives to 
remove them from the stomach and intestinal 
canal are indicated. After thorough action from 
these, attempts may be made to destroy such of 
the parasites as have escaped the action of the 
emetic or purgative. For this purpose glycerin 
1 part, water 2 parts, is much in favor; or a trial 
can be made of carbolic acid and tincture of iodin, 
as suggested by Bartholow. Quinin has given 
good results. 
After migration has begun, the vital powers 
should be sustained by nourishing food, stimulants, 
and tonics, as there are no drugs that have any 
influence upon the embryos in their migration 
through the muscles. 
TRICHLORACETIC ACID.-A monobasic or- 
ganic acid (CC13.COOH) obtained from the oxida- 
tion of chloral hydrate with nitric acid. It should 
be kept in dark well-stoppered bottles in a cool 
place. While penetrating deeply it does not cause 
as much pain as many other escharotics. It is 
used locally in lupus, condylomata, etc., and for 
cauterization of the nose or throat. 
TRICHOPATHY (Trichosis).-Any morbid affec- 
tion of the hair. See Alopecia,Canities, Hirsuties. 
TRICHOPHYTOSIS.-See Ringworm of the 
Scalp. 
TRICRESOL.-A mixture of the three isomeric 
cresols, respectively named the ortho-, meta-, and 
paramethyl phenols; it also contains the hydroxyl 
group, which seems to be a characteristic con- 
stituent of antiseptics and germicides. It occurs 
as a white liquid of creosote-like odor (sp. gr. 
1.052 to 1.049), and is soluble in water. Tricresol 
possesses very high germicidal power, and is said 
to be practically nontoxic, and less irritating to 
wounds than either carbolic or sublimate solutions. 
A 1:1000 solution dropped into the eye produced 
not the slightest irritation. Such solutions may, 
therefore, be advantageously employed as men- 
strua for the stock collyria, especially for those 
of cocain, physostigmin, and atropin, which are 
most liable to contamination. Tricresol is par- 
ticularly fatal to pyogenic cocci, a 1 percent solu- 
tion invariably killing them in 1/2 minute in 
watery solutions, and in 1 1/2 minutes in rich 
albuminous fluids (Gruber). See Phenol. 
TRIFACIAL NERVE, AFFECTIONS.-This im- 
portant mixed nerve of the face supplies, by its 
motor trunk, the muscles of mastication; by its 
sensory portion, the skin of the face, the mucous 
membrane of the mouth and nasal cavity, the 
conjunctiva and cornea, also the anterior part of 
the tongue with gustatory fibers. The gustatory 
fibers reach the lingual fibers of the fifth by the 
chorda tympani nerve. 
Lesions.-1. There may be lesions of the pons, 
especially hemorrhage, or spots of sclerosis invad- 
ing the trigeminal nucleus. 
2. Injury or disease at the base of the skull, 
especially acute and chronic meningitis and caries 
of the bone; tumor; syphilis; new formations com- 
female are in a state of motion, and at once migrate 
from the intestines to the muscular structure of 
the individual, and here set up inflammatory 
action; they becoming surrounded by a capsule or 
shell in which they are coiled. After a time, in 
the muscle, the trichina undergoes a further 
change: lime salts are deposited in and about the 
capsule and in the parasite itself, and minute 
specks of lime are seen distributed throughout the 
muscular structure. The development of the 
parasite from the period of the impregnation up to 
the time of sexual maturity is, under favorable 
conditions, less than 3 weeks. Within 2 days 
from the ingestion of the infected pork occurs the 
maturation of the muscle larvae; in 6 days more 
the birth of embryos occurs, and in about 2 weeks 
the migrating progeny have arrived at their habi- 
tat, the muscular structure. 
The prognosis depends upon the amount of infec- 
tion in the pork or beef. Mortality is between 20 
and 50 percent. 
Trichina Spiralis.-{Ziegler.) TRIFACIAL NERVE, AFFECTIONS 
TRITICUM 
pressing the trunk or Gasserian ganglion. Frac- 
ture of the base rarely affects this nerve. 
3. Tumors or aneurysms pressing on the first 
division (ophthalmic) of the nerve through the 
cavernous sinus, on the second division (superior 
maxillary) and on the third division (inferior maxil- 
lary) by invasion of the sphenomaxillary fossa. 
4. There may be inflammation of the nerve, 
which is rare. 
The sensory division may also be affected in 
hysteria and in lesions of the posterior part of the 
internal capsule. The gustatory fibers of the 
trigeminus may be influenced by peripheral lesions 
of the facial nerve, from which the chorda tympani 
is derived. 
Symptoms. Paralysis of the Sensory Portion.- 
The distribution of the anesthesia varies according 
as the whole trigeminus or only a half is involved. 
In total anesthesia there is loss of sensation in half 
the corresponding side of the head, including the 
conjunctiva and cornea, mucosa of the lips, tongue, 
hard and soft palates, and nose of the same side. 
Hence on the tongue or mucous membranes there 
are often ulcers that come from unconscious lacera- 
tion by the teeth. There is loss of taste and im- 
pairment of smell. The muscles of the face are 
also insensible, hence their movements are slower. 
The so-called trophic phenomena are also observed, 
and among them the much-discussed neuropara- 
lytic ophthalmia, an ulcerative keratitis, beginning, 
always in the lower segment of the cornea, and 
passing over into purulent inflammation of the 
whole eyeball. It seems, on the whole, more 
likely that the inflammation is primarily due to the 
action of irritants that in health are excluded by 
the proper closure of the eyelids, though the in- 
flammatory process itself may be trophically 
influenced. The salivary, lacrimal, and buccal 
secretions may be diminished, and the teeth may 
become loose. Herpes is a trophic result that may 
develop in the course of the nerve, is painful, and 
may last a long time. So, too, the anesthesia may 
be preceded by tingling. The skin of the face is 
sometimes swollen. 
Paralysis of the motor portion, which supplies 
especially the muscles of mastication, the masse- 
ters, temporals, and pterygoids, is not common. 
It is most frequent in diseases of the base of the 
skull, compressing this branch. Difficulty in 
chewing is the result. If on one side, the patient 
can only chew on the other; if on both sides, he 
cannot chew at all. The lower jaw hangs down 
and cannot be moved from side to side because of 
the paralysis of the pterygoids. If on one side, the 
external pterygoid cannot push the jaw toward the 
sound side; and when depressed, the jaw is pushed 
by the muscle of the sound side toward the para- 
lyzed side. Cases have occurred associated with 
cortical lesion; from one of these Hirt inferred 
that the motor center for the trigeminus is in the 
neighborhood of the lower third of the ascending 
convolution. 
Spasm of the muscles of mastication occurs in 
connection with muscular cramp, the muscular 
contraction of tetanus (trismus), sometimes in 
tetany and meningitis, and reflexly through painful 
affections of the jaw or teeth, or from irritation 
near the motor nucleus. It is at times hysteric. 
Clonic spasm occurs in muscles supplied by the 
fifth nerve, constituting "chattering teeth." It 
occurs usually in connection with general condi- 
tions, such as chorea, but it may arise as a local 
symptom in women late in life (Tyson). 
Diagnosis is not difficult. Sensibility is tested 
in the ordinary way. The preliminary pain must 
not be mistaken for neuralgia. Gustatory sense is 
tested in the anterior end of the tongue by applying 
weak acid or salt solutions and comparing the 
effect on the two halves. The motor power is 
tested by biting on a piece of wood or by moving 
the jaws against resistance. 
Treatment must depend upon-the cause, which 
should be carefully sought. Syphilitic new forma- 
tions are the lesions most commonly amenable to 
treatment. In the absence of such causes the treat- 
ment must be symptomatic. Stimulating liniments 
and faradization through the electric brush are 
often useful. Galvanism may also be used, brush- 
ing the part with the kathode. The anesthetic 
part should be carefully protected against irritants. 
TRIGEMINAL NERVE.-See Trifacial Nerve. 
TRIGGER FINGER.-Trigger finger or snap fin- 
ger is an acquired deformity in which one or pos- 
sibly two fingers can be extended only by great 
effort or by using the other hand, when the finger 
flies out like the blade of a penknife. Over 90 
percent of the cases are caused by some condition 
that offers a limited obstruction to the play of the 
tendon in its sheath, e.g., contraction of the sheath, 
enlarged sesamoid, ganglion, a growth on the 
tendon, or, most frequently, a localized fibroid 
thickening of the tendon, the lesion usually being 
situated over the metacarpophalangeal joint, at 
which point the "tendon callus" can often be felt. 
In less than 10 percent of the cases the trouble is 
due to an alteration in the relations of the joint 
surfaces the result of injury or disease. The 
treatment is removal of the obstruction. In the 
usual variety it is necessary only to incise the 
theca over the fusiform enlargement of the tendon 
(Stewart). 
TRIONAL.-Diethylsulphonethylmethyl meth- 
ane. It is a powder consisting of shining tablets, 
which dissolve in 320 parts of cold water, readily 
in alcohol and ether, and have a distinctly bitter 
taste. Trional is administered in fine powder dis- 
solved in liberal quantities of some liquid. Dose, 
10 to 30 grains daily. Trional differs from sul- 
phonal only in the substitution of an ethyl for a 
methyl group. It is an efficient hypnotic, and is 
less liable to produce ill effects than sulphonal, but 
must be given in doses fully as large. In cases of 
slight psychic excitement accompanied by obsti- 
nate insomnia it is peculiarly efficient. See 
Lambert Treatment for Narcotic Addiction. 
TRITICUM (Couch-grass).-The dried rhizome 
of Agropyron repens. It is emollient, diuretic, and 
antiphlogistic; and is useful in cystitis and irritable 
bladder. It is tbest administered in a decoction 
made from 2 to 4 ounces of the plant in 2 pints of 
water, and reduced one-half by boiling. The dose 
of triticin is from 1 dram to 1 ounce in infusion. TRITURATIONS 
TRUSS 
The dose of the fluid extract is fj-om 1 dram to 1 
ounce, well diluted. 
TRITURATIONS.-A class of powders having for 
their diluent sugar of milk, and possessing a definite 
relation between the active ingredient and the 
diluent. The Pharmacopeia prescribes a general 
formula for these preparations, according to which 
10 grams of the substance and 90 of sugar of milk 
are to be well mixed by a spatula, the latter being 
added in successive quantities, and both triturated 
in a mortar until the substance is intimately mixed 
with the diluent and finely comminuted. There 
is but one official trituration (trituratio elaterini), 
though the pulvis ipecacuanha et opii practically 
belongs to this class. Sugar of milk is employed 
as the diluent because of its hardness and its com- 
parative insolubility. 
TROCHES (Trochisci).-Also called Lozenges, 
and Pastilles. Small, flattened cakes of medicinal 
substances prepared from a mass consisting chiefly 
of medicinal powders, sugar, and mucilage. 
There are 9 official troches: 
TROPACOCAIN.-A powerful anesthetic and 
mydriatic, derived from a small-leaved coca of 
Java. It has the general qualities of cocain, but 
appears to be more active and much less toxic. 
The hydrochlorid is applied in 3 to 10 percent 
solution in 0.6 percent sodium chlorid solution. 
See Cocain. 
TROPHIC DERANGEMENTS.-See Nervous 
Diseases (Examination). 
TRUSS.-An instrument for maintaining a part 
in proper position in hernia or other malposition of 
organs. 
Trusses should exert pressure sufficient to a 
little more than completely retain a hernia under 
all conditions and in all positions of the body. In 
reducible hernia continued use of a truss, par- 
ticularly in young persons, may effect a cure. It 
is important that a truss should be fastened in 
position before rising in the morning and that it 
shall be removed after lying down at night. Dur- 
ing the night a light or special truss may be worn, 
and also in bathing. When a portion of omentum 
constitutes the hernia, the gut being replaceable, 
it is very difficult to maintain reduction. A femoral 
hernia, is always more difficult to keep reduced 
than an inguinal hernia; and in fleshy persons 
adjusting a truss is troublesome. 
Trusses are always uncomfortable at first, a 
feeling which is soon overcome. If a truss fits, it 
retains the hernia reduced even in sitting so that 
the abdominal walls are relaxed, and when cough- 
ing and straining occur. If pain results from the 
use of a truss, or it does not retain the hernia, it is 
harmful. A spring which is too strong will enlarge 
the hernial opening, and may aggravate the case. 
A truss should be worn for a long time after an 
apparent cure. 
To measure for a truss (MacCormac's rule).-In 
either inguinal or femoral hernia the lower part of 
the hernial opening is the point of starting for 
measurement; thence measure up to the anterior 
superior spine of the ilium on the same side, thence 
around the body 1 inch below the crest of the ilium 
to the other or opposite anterior superior • iliac 
spine, and then to the upper part of the hernial 
opening. 
Trusses are composed of different materials 
elastic as steel or vulcanite, and inelastic, as 
leather, calico, or jean. The last kind does 
not exert sufficient pressure, but is sometimes of 
service in a large irreducible or umbilical hernia. 
The pad is usually made of hard rubber, vulcan- 
ite, or xylonite, or of cork covered with flannel, 
linen, and wash-leather. Water- and air-cushions 
may be used, especially if the surface is painful or 
irregular. Boxwood, ebony, ivory, or other firm, 
nonabsorbable materials are sometimes employed. 
The pad for an inguinal hernia is pear-shaped, and 
about 3 inches long, 2 inches at its broadest part, 
and about 3/4 of an inch in thickness. The outer 
surface is flat, and has two studs for attachment 
of straps. The inner surface is convex, looking 
upward as well as backward-especially so when 
the abdomen is protuberant-and it lies upon the 
internal ring and the inguinal canal, and although 
not touching, may come quite close to the pubic 
Title. 
Constituents-100 
Troches. 
Each Troche 
Contains: 
Trochisci: 
Acidi tannici.. 
Tannic acid, 6 gm.; pow- 
Tannic acid, 1 
Ammonii chlo- 
dered sugar, 65 gm.; pow- 
dered tragacanth, 2 gm.; 
stronger orange flower 
water, a sufficient quan- 
tity. 
Ammonium chlorid, 10 
grain. 
Ammonium 
ridi. 
gm.; extract of liquorice, 
chlorid, 2 
Cubeba 
20 gm.; powdered traga- 
canth, 2 gm.; powdered 
sugar, 40 gm.; syrup of 
tolu, a sufficient quantity. 
Oleoresin of cubeb, 2 gm.; 
grains. 
Oleoresin cubeb, 
Gambir 
oil of sassafras, 1 c.c.; ex- 
tract of liquorice, 25 gm.; 
powdered acacia, 12 gm.; 
syrup of tolu, a sufficient 
quantity. 
Gambir, powdered, 6 gm.; 
i grain. 
Gambir, 1 
Glycyrrhizae et 
powdered sugar, 65 gm.; 
powdered tragacanth, 2 
gm.; stronger orange flower 
water, a sufficient quantity 
Extract of liquorice, 15 gm.; 
grain. 
Powdered opi- 
opii. 
powdered opium, 0.5 gm.; 
um, i grain. 
Krameria; 
powdered acacia, 12 gm.; 
powdered sugar, 20 gm.; 
oil of anise, 0.2 c.c.; water, 
a sufficient quantity. 
Extract of krameria, 6 gm.; 
Extract of 
Potassii chlora- 
powdered sugar, 65 gm.; 
powdered tragacanth, 2 
gm.; stronger orange flow- 
er water, a sufficient 
quantity. 
Potassium chlorate, 15 gm.; 
krameria, 1 
grain. 
Potassium 
tis. 
powdered sugar, 60 gm.; 
powdered tragacanth, 3 
gm.; water, a sufficient 
quantity. 
Santonin, 3 gm.; powdered 
chlorate, i 
Santonini 
grain. 
Santonin, J 
Sodii bicarbon- 
sugar, 90 gm.; powdered 
tragacanth, 3 gm.; strong- 
er orange flower water, a 
sufficient quantity. 
Sodium bicarbonate,18 gm.; 
grain. 
Sodium bicar- 
atis. 
powdered sugar, 54 gm.; 
b o n a t e , 3 
bruised nutmeg, 1 gm.; 
mucilage of tragacanth, a 
sufficient quantity. 
grains. TRYPANOSOMIASIS 
TUBERCULIN 
spine. When the hernia is congenital, the so- 
called rat-tailed shape is usual. The pad is pro- 
longed downward between the thigh and scro- 
tum, gradually tapering off. A double truss is 
sometimes here preferable, particularly if the de- 
formity is direct or is an old oblique hernia, the 
rings of which have been dragged nearly opposite 
to each other. A double truss is not more incon- 
venient than a single one. 
The pad for an oblique inguinal hernia is some- 
times cut like a horseshoe with one side (which 
covers the inner pillar) longer than the other. The 
rupture is prevented from descending by the ten- 
sion across the opening. For a direct hernia 
this principle requires that the shape of the pad be 
that of a ring, the center of which corresponds 
with the axis of the hernial opening. 
For femoral hernia the pad is smaller, and is 
beveled a little on the outer side, to avoid pressure 
upon the femoral vein, and is also beveled above, 
so that it may fit well under Poupart's ligament 
and bring the walls of the canal together. 
A shallow concave plate is used for umbilical 
hernia, the truss at the same time supporting the 
lower parts of the abdomen. Nipple-shaped 
projections only enlarge the hernial openings. 
As a rule, the pad is rigidly fastened to the spring, 
but a ball-and-socket joint is sometimes used, and 
in other trusses the pad may be shifted up or down 
and fastened in any position. The under-strap of 
a truss should always be fastened to the lower stud 
on the back of the pad, to prevent its riding up. 
It should be moderately tight when the patient is 
in the upright position. 
To test a truss, the patient should sit on the edge 
of a chair, with the knees separated so that the 
structures around the ring are relaxed. He should 
then be directed to strain downward. If the 
rupture does not escape, the pad fits the opening 
and the pressure is sufficient. Too strong pres- 
sure tends to cause absorption of tissues beneath. 
If the skin beneath the truss or pad becomes sore 
or excoriated, it may be, bathed in cologne water or 
alcohol to harden it, and dusted with violet 
powder. 
An irreducible hernia may be inclosed in a hinge- 
cup made of rim-plate covered with leather, or 
may be supported in a laced bag-truss. Belts 
may be required for ventral or umbilical pro- 
trusions. For the congenital hernia of children a 
skein of Berlin wool may be used. For irreducible 
hernia in the aged a bag-truss, laced up on one side, 
or a cup made of soft leather supported by a metal 
rim, may be used. Sometimes the truss may be 
made of metal molded on a cast taken from the 
hernia while it is smallest. See Hernia. 
TRYPANOSOMIASIS.-See Sleeping Sick- 
ness. 
TRYPSIN.-The proteolytic enzyme of pan- 
creatic juice. Its powers are manifested in an 
alkaline medium, converting proteids into pep- 
tones. Traces of trypsin are said to have been 
found in urine, but this is doubtful. It is recom- 
mended for spraying the throat in membranous or 
diphtheritic croup. Thirty grains are dissolved in 1 
ounce of water, 10 grains of sodium bicarbonate 
are added, and the mixture is applied by means of 
a brush or as a spray. 
TUBAL ABORTION.-Internal rupture of a 
tubal pregnancy, with extrusion of blood, and 
possibly of the ovum, through the fimbriated 
extremity of the tube into the abdominal cavity. 
See Etrauterine Pregnancy. 
TUBAL PREGNANCY.-See Extrauterine 
Pregnancy. 
TUBERCULIN.-Koch's lymph. A glycerin 
extract of cultures of the bacillus of tuberculosis. 
For a time tuberculin was thoroughly discredited. 
It has, however, become of interest again by reason 
of the efforts to extract from it a germicidal con- 
stituent free from toxins, also by the results ob- 
tained in tuberculosis with the blood serum of 
animals immunized by its repeated inoculation. 
It is extremely valuable in the diagnosis of tuber- 
culosis in cattle and recently it has been 
gaining favor in the diagnosis of human tuber- 
culosis. See Tuberculosis (Pulmonary). 
Test.-A hypodermic injection of 1 to 10 mg. 
of pure tuberculin is given. "Reaction" consists 
in a rise of temperature of 1 1/2 to 2° F. within 
12 hours after injection. 
Modifications.-The opthalmo-reaction of Wolff- 
Eisner and Calmette. See Vaccine Therapy. 
Cutaneous Reaction (of von Pirquet). Technic. 
-After the skin of the fore-arm has been scrubbed 
with ether, two drops of undiluted tuberculin are 
ropped on it about 4 inches distant from each 
other. Then with a special vaccination-lancet a 
superficial scarification is made between the two 
drops on the dry surface. Finally the same scari- 
fication is made inside of the two drops. A few 
fibers of cotton are put on the drops so that they 
will not flow. After five minutes the cotton is 
taken off, but no dressings are to be applied. The 
reaction is best examined after 48 hours. It is 
considered positive when the tuberculous scarifi- 
cations are clearly different from the control place, 
but the ordinary reactive area must measure at 
least 1/6 of an inch. 
Remarks on the Technic.-Scrubbing the skin 
with other substances than ether is not advisable, 
because if one applies a watery solution of an anti- 
septic character (or alcohol) the skin does not dry 
very quickly and so the drop of tuberculin runs, 
and is diluted; ether alone allows a very quick 
drying. 
Old tuberculin in full strength has the advant- 
age over diluted tuberculin in that no preparation 
is necessary, and that the substance keeps an TUBERCULIN 
indefinite time, as it contains a large amount of 
glycerin and some carbolic acid. The old tuber- 
culin used is the extract of tubercle bacilli which 
was indicated by Koch in 1891. It is perhaps best 
to use the original preparation bought of Lucius 
and Bruning in Hoechst a/M, but similar prep- 
arations are also manufactured in America. 
The special vaccination lancet, advised by v. 
Pirquet for this purpose differs from an ordinary 
one in the form of its tip, which is not pointed 
but has a crescent shape like a small chisel. This 
tip is made of platinum, so that it can be cleaned 
by exposing it to heat. The abrasions are not 
made as in vaccination, by scratching; but by 
turning the instrument quickly. As the point 
is about 1/12 of an inch, it gives a round abrasion 
of the same diameter. The turning should be 
made with a slight pressure, the intensity of which 
must vary with the quality of the skin. In small 
children very slight pressure is sufficient; in adults 
one must exert more. The abrasion should be 
quite superficial, taking off the epidermis only, 
and no blood should escape. The abrasion which 
is made first is used for the control of the trau- 
matic redness. Each scratch on the skin causes a 
slight traumatic reaction, the intensity of which 
depends on the individual. It is therefore neces- 
sary to compare the tuberculin points with an 
ordinary scratch of the same size. One could 
apply for that purpose some fluid, such as physio- 
logic salt solution or bouillon, but as it was proved 
that scratches with these different fluids show no 
more reaction than a scratch with no fluid, it is 
simpler to make it without the fluid. The fibers 
of cotton are only to be used if the drops are large. 
Pirquet usually allows them to fall from a dropper, 
but one can also do the following: The tuberculin 
is kept in a glass tube with a long glass stopper; 
the point of the lancet is moistened with the end 
of the glass stopper; in this way there is practic- 
ally no drop left, and the cotton need not be used. 
The best moment of control is after 48 hours; but 
it is advisable to look at the points several times, 
say after one, two and seven days. 
Description of the reaction.-(1) Traumatic 
reaction: The vaccination and control points show 
the same condition at first. Within a few minutes 
a hive-like appearance is noticed, with a slight red 
margin; this disappears after some hours. After 
24 hours one finds in the control point a brown 
scab with a slight redness around it which dis- 
appears in 48 hours. 
(2) Vaccination points with negative reaction 
act like the point of control, only at times they are 
a little bit more elevated. In case there is any 
doubt of a positive reaction, the vaccination is to 
be repeated. 
(3) The positive reaction, (a) Time of latency 
(3 hours to several days). During the first hours no 
specific action of the tuberculin is noticed, but only 
the traumatic one. In most cases the reaction is 
in its full height in 24 to 48 hours, (b) Growth. 
The inflammatory reaction begins usually as a 
slightly elevated papule at the point of scarifica- 
tion, which increases in height and diameter; the 
final diameter of a positive reaction is on an aver- 
TUBERCULIN 
age about 1/2 inch, but is sometimes one inch or 
more. There are also great individual differences 
in the exudation. If the papules are very large, 
the central part is also usually very elevated, with 
sometimes small serous blisters, or even one large 
blister on the top of it. The color too is very 
different; as a rule, strong individuals with.a good 
general color of the skin show papules of intense 
redness, while anemic individuals show slightly 
colored reactions. Sometimes there is scarcely 
any hyperemia, and one notices the papule on 
palpation only. This is often the case in colored 
people. On the other hand, reactions may occur 
which consist only in redness, and show no exuda- 
tion. This is especially the case in miliary tuber- 
culosis or in tuberculous emaciation. The out- 
lines of the papule are generally distinct, and cir- 
cular in outline; but sometimes it shows irregular 
rays, which point in the direction of the lymphatic 
vessels. In cases of scrofulo-tuberculosis, one 
often finds very small papules near the reaction 
but not in direct connection with it. The hypere- 
mia does not generally extend over the margin of 
the exudation; but in intense reactions one often 
meets after 48 hours a slightly reddened margin 
surrounding the central exudation, which margin 
may be even 2 inches in diameter, (c) Reforma- 
tion.-Generally papules begin to decrease 48 hours 
after the vaccination. The redness at first changes 
to violet and then to a brownish color followed 
by pigmentation which may persist for a month 
or longer, whereas the exudation disappears within 
the first week, (d) The Slow and Secondary Re- 
action.-There are cases in which the positive re- 
action appears only after two, three, or six days. 
They have a somewhat different meaning from the 
early reaction, and are very nearly related to the 
cases of "secondary reaction," in which the posi- 
tive issue of a second vaccination occurs five to 
ten days after the first one. 
Other Actions of the Cutaneous Test.-In v. 
Pirquet's method of making only very superficial 
abrasions, a general reaction of the organism 
practically never occurs; a slight elevation of tem- 
perature being noted in about 1 percent of cases. 
However, minimal amounts of tuberculin certainly 
enter the general circulation, for we often see that 
the sensitiveness to tuberculin is increased after a 
vaccination. The cutaneous reaction has practi- 
cally no contraindication. One can use it at 
every age and in spite of every degree of fever. 
Histologic Findings.-The inflammation of the 
cutis sh,ows a tuberculous inflammation but with- 
out tubercle bacilli. It contains specially a large 
number of mononuclear cells. 
The Meaning of Positive and Negative Reactions. 
-A positive reaction means that the organism con- 
tains antibodies against tuberculosis. As these 
antibodies are only acquired by an infection of the 
individual, it means consequently that the organ- 
ism has had to struggle against the infection with 
tuberculosis. The reaction itself does not say 
at all what the result of that struggle was. It may 
be that the infection led to a very large focus forma- 
tion of the microorganism, or it may be that only 
some glands became tuberculous. That every posi- TUBERCULIN 
TUBERCULOSIS 
tive reaction means infection with tuberculosis, has 
been proved by a great number of postmortem 
examinations. In autopsies of 164 children who 
had given a positive reaction, in 161 a tuberculous 
focus was found, and only in three cases the patho- 
logic investigation was negative. It is very 
probable that even in these cases some small focus 
escaped detection. The cutaneous reaction is 
practically the same as Koch's fever reaction; and 
we know, that in cattle, with every distinct posi- 
tive reaction we find some tuberculous lesion also, 
the size of which may be very variable. An in- 
tense positive reaction means that a tuberculous 
infection has occurred recently, or that in an old 
tuberculosis some progress or some reinfection has 
taken place. As to the extent and the localiza- 
tion of the focus, we can say nothing from the size 
of the reaction, but we must use all methods of 
physical examination to determine where the 
lesion is. 
(2) A negative reaction means in general that 
the patient has no tuberculous affection. One 
cannot absolutely depend on a single negative 
issue, and it is safer to repeat the reaction after a 
week. In case it is then negative again, we can 
say almost with certainty that the patient does not 
contain a tuberculous focus. This certainty, 
however, is never an absolute one, because there 
are several reasons why a patient in spite of his 
tuberculous focus may contain few or no anti- 
bodies. In this way the following reasons for a 
negative issue have to be noted, (a) Last stage 
of lung tuberculosis or emaciation from tuberculosis 
of other organs. In very progressive tuberculosis 
the reaction often fails, so that it was even found 
that one could use a negative reaction in a certain 
tuberculosis as a sign of an unfavorable prognosis. 
Stress should not be laid on the issue of the 
cutaneous reaction in progressive tuberculosis, 
(b) In acute miliary tuberculosis and in tuber- 
culous meningitis the reaction generally fails one 
or two weeks before death, but here also this is 
not invariable, as we see cases in early childhood re- 
taining a positive reaction up to the last day of life, 
(c) During tuberculin treatment: If a patient is 
treated regularly with an ascending amount of 
tuberculin injections, he loses his cutaneous reac- 
tivity after a certain point of immunization is 
reached, (d) During measles with the onset of the 
exanthem, the positive reaction of tuberculous 
patients disappears and reappears only about a 
week afterward. This point up till now has found 
no exception, so that one is able to make the diag- 
nosis of measles if a tuberculous child loses its 
reactivity during an exanthem of a doubtful char- 
acter. (e) Besides these examples there are some 
cases with little or no reactivity in spite of a 
tuberculosis, in which we cannot yet indicate the 
reason why the antibodies are lacking. As a rule, 
cases with a very slight reactivity, that is with a 
small papule or a late or secondary papule forma- 
tion, denote some slight and inactive tuberculous 
lesions, but one cannot depend on this rule in 
every case. 
slight affections of tuberculosis are so common 
that the presence of a positive reaction alone does 
not tell us very much. There are only two things 
in adults which can be used: (1) A very intense 
reaction after the first trial, which indicates a fresh 
infection or reinfection; (2) a repeated nega- 
tive issue of the trial, by which one is able to ex- 
clude tuberculosis. In children the infection with 
tuberculosis is not so common as in adults, and 
the younger the children are, the more dangerous 
is the infection. Thus, in an apparently healthy 
child of 10 years, showing no organic lesion, a 
positive reaction will not disturb us, whereas in a 
child of one year every positive reaction means a 
serious danger. In children, furthermore, the 
positive reaction gives a great aid to the diagnosis 
of some disease in question,'as at this age infec- 
tions with several kinds of bacteria are not so com- 
mon as in adults, and therefore one can be almost 
certain that some symptom in question, say a 
bronchitis, if the tuberculin reaction is positive, 
is due to the same microorganism. 
The cutaneous tuberculin reaction should be 
used in private practice only if some symptom 
leads to the suspicion of tuberculosis; for instance, 
if children are pale or without appetite, or have 
a bronchitis, some skin affection, etc. In hospi- 
tals, however, the test has been recommended as a 
routine examination of every child accepted, in 
the same way as we examine the urine in every 
case. Finally in orphan asylums which treat 
children up to 5 or 6 years, the cutaneous test 
should be used as a prophylactic means to segre- 
gate the tuberculous children from those who are 
free from tuberculosis. See Vaccine Therapy. 
Moro's Inunction Test.-An ointment of 50 per- 
cent tuberculin in lanolin is rubbed into the skin 
of the chest or abdomen which is left exposed for 15 
minutes. In a few hours to three days, papules 
and probably erythema will appear if the in- 
dividual is affected. And see Vaccine Therapy. 
The methods of von Pirquet and Moro are 
entirely innocuous. 
TUBERCULOSIS.-An infectious disease due 
to the introduction into the system of the bacillus 
tuberculosis, discovered by Koch in 1882., It has 
a very wide-spread, almost a universal, distribution, 
and it is estimated that fully one-seventh of all 
mankind die of it. 
Etiology.-The bacillus, the essential etiologic 
factor, gains entrance into the body with the 
inspired air, with the food, and by direct inocula- 
tion. The commonest mode of introduction is by 
inhalation; in consequence, the respiratory tract 
is the most frequent seat of tuberculosis. The 
bacilli become disseminated in the air chiefly 
through the agency of the sputum of persons 
afflicted with pulmonary tuberculosis. The 
sputum of such individuals contains countless 
bacilli, which are held in it as long as it is moist, but 
are scattered through the air when the sputum 
becomes dry and pulverulent. When tuberculo- 
sis is acquired through the food-an occurrence 
not rare in childhood- it localizes itself primarily 
in the intestinal tract. The food that most often 
conveys the disease is milk from tuberculous 
As to the practical application, adults and 
children must be considered separately. In adults TUBERCULOSIS 
TUBERCULOSIS 
animals, more rarely tuberculous meat. Direct 
inoculation does not play an important role in the 
causation of the disease. 
The status of heredity as a factor in the prop- 
agation of tuberculosis is not yet fully settled. 
Isolated instances of apparently hereditary trans- 
mission, both in man and in animals, are recorded 
and demonstrate that the disease may be inherited; 
but in the majority of cases the acquisition of 
tuberculosis is postnatal. There is, however, a 
manifest tendency of the disease to attack the 
offspring of tuberculous parents, which, as it is not 
the result of hereditary transmission, must indicate 
the existence of a predisposition or susceptibility, 
which is transmitted from parent to child. 
The bacillus of tuberculosis is a short, rod-shaped, 
nonmotile bacterium, 3 to 4 micromillimeters in 
length, and from 1/6 to 1/8 as broad as it is long, 
often slightly curved, and when properly stained 
with anilin dyes, occasionally has a beaded appear- 
with alcohol, clear, and mount. A good and 
quick method but not so reliable as the preceding. 
Koch-Ehrlich Method.-Stain the cover-glass 
preparation for 24 hours at the temperature of the 
room, or for 15 minutes with heat in anilin water, 
alcoholic solution of fuchsin, gentian-violet, or 
Tubercle Bacilli in 
Sputum.-(Greene.) 
Tubercle Bacilli in 
Urine.-(Greene.) Ob- 
serve tendency to form 
groups. 
methyl-violet (prepared by adding to anilin water 
enough of a concentrated alcoholic solution of 
the dye to produce opalescence). Then immerse 
the preparation in 33 percent nitric acid, and when 
it assumes a yellow-green tint, transfer to 70 
percent alcohol. Counterstain 1 to 5 minutes in 
methylene-blue, malachite green, or picric acid 
for fuchsin; in Bismarck brown for gentian- 
violet or methyl-violet. Wash in water, dry, 
and mount in balsam. Prolonged action of the 
nitric acid will decolorize the bacilli. 
Unna's Method.-Stain for from 10 minutes to 
several hours in polychromic methylene-blue 
(Griibler's) wash in water, and treat with a 33 per- 
cent aqueous solution of tannic acid for from 2 to 5 
minutes. Wash thoroughly, and transfer to 
absolute alcohol, gold-orange alcohol, or to 25 
percent nitric acid; follow with dilute alcohol, 
water, and absolute alcohol. Clear in bergamot 
oil. This process double stains tubercle bacilli 
and leprosy bacilli. 
And see Urine Examination. 
The lesion produced by the growth of the bacillus 
of tuberculosis is known as the tubercle (miliary 
Bacillus Tuberculosis, from a pure Culture. 
(X1000).-(.Williams.) 
ance. Its characteristic staining property is due 
to the fact that after being stained with carbol- 
fuchsin it is not subsequently decolorized by im- 
mersion in a strong solution of nitric acid. 
Methods of Staining. Ziehl-N eelsen Method.- 
Float the cover-glass preparation upon Ziehl's 
carbolfuchsin-saturated alcoholic solution of 
fuchsin, 10 c.c.; 5 percent phenol water, 90 c.c. 
Heat until vapor arises (about 3 to 5 minutes), 
wash in water, and decolorize in 15 percent nitric, 
or 5 percent sulpuric, acid, then in 60 to 80 percent 
alcohol to remove the remnant of color. Wash 
well, dry, and mount in balsam. In the case of 
tissue-sections stain cold for 15 minutes, and de- 
colorize as detailed; upon removal from the alcohol, 
counterstain with methylene-blue, wash, dehy- 
drate, clear, and mount. 
Gabbett's Modification of Frankel's Method.- 
Stain in Ziehl's carbolfuchsin for about 2 minutes 
without heating, wash in water, stain in 25 percent 
sulphuric acid (100 c.c.) and methylene-blue 
(2 c.c.) for 1 or 2 minutes, wash in water, dry, 
andr mount. In the case of sections dehydrate 
Diagram of the Minute Structure of Tubercle. 
(Walsham.) 
or gray tubercle or nodule). This is a small, 
grayish, translucent nodule, from 1/10 to 2 mm, 
in diameter, firmly embedded in the surrounding 
tissues. By the coalescence of neighboring TUBERCULOSIS 
TUBERCULOSIS, ACUTE MILIARY 
tubercles large masses, the so-called tubercular 
infiltrations, are produced. Histologically, a 
typical tubercle consists of 3 groups of cells- 
the epithelioid, the giant cells, and the round or 
lymphoid cells. The first are oval in shape, have 
a vesicular nucleus, and are the result of the pro- 
liferation of the fixed connective tissue and en- 
dothelial cells; perhaps, also, of epithelial cells. 
The formation of the oval cells is the first effect 
produced by the tubercle bacillus. The giant cell 
is a large, multinuclear mass, usually situated in 
the center of the tubercle. It may be the product 
of repeated nuclear multiplication in a single 
cell, without division of the cell protoplasm, or 
the result of the coalescence of several adjacent 
cells. The round cells are leukocytes that have 
emigrated from the blood-vessels, and they may 
be so numerous as to conceal the other cells 
(lymphoid tubercle). The bacilli are found in 
the giant cells, between and in the epithelioid 
cells, and, in later stages, in the round cells. New 
blood-vessels are not formed in the tubercle. 
The tendency of the tuberculous formation is to 
undergo a peculiar form of coagulation, known as 
cheesy necrosis. This gives rise to a structureless, 
yellowish-white mass, which microscopically shows 
an almost total absence of nuclei in the central 
area, while at the periphery, nuclei, both normal 
and in various stages of degeneration, are found. 
The necrotic tissue does not, as a rule, take any 
stain. For this degeneration two factors are 
responsible-the absence of blood-vessels and the 
action of peculiar poisons elaborated by the 
bacillus. The breaking down of tuberculous areas 
in the interior of organs gives rise to cavities, 
which may be seen in muscles, bones, brain, 
lymphatic glands, and elsewhere, but are most 
pronounced in the lungs, where they may attain 
a very large size. On surfaces-skin and mucous 
membranes-tuberculosis often leads to the 
formation of ulcers, which are characterized 
by an irregular, eroded appearance, and by the 
presence of tubercles. Tuberculous areas occa- 
sionally become secondarily infected with pyo- 
genic or saprophytic organisms. The tubercle 
bacillus itself is capable of producing pus, but the 
majority of the so-called tuberculous cold abscesses 
are merely collections of fatty and disintegrated 
cells and tissue detritus. 
Tuberculosis is primarily a local disease-exten- 
sion takes place by continuity and contiguity 
along the lymph channels, along the respiratory 
and intestinal tracts, and through the blood. It 
is usually possible in secondary tuberculosis to 
demonstrate the original focus, but in the case of 
tuberculous lymphatic glands the source of infec- 
tion is not always discoverable. This has been 
explained by assuming that infection may take 
place in utero, and the bacilli lie dormant in the 
lymphatic glands for varying periods after birth 
(latent tuberculosis). The possibility has also 
been suggested that the bacilli may penetrate a 
mucous membrane, be carried to the nearest 
lympathic gland, and unfold their activity there. 
In the human subject tuberculosis appears 
under various forms, presenting clinical differences, 
but identical from the pathologic standpoint. 
Since the discovery of the tubercle bacillus such 
diseases as scrofula, lupus vulgaris, Pott's disease, 
many forms of chronic joint-disease, and the ana- 
tomic tubercle have been proved to be tubercu- 
lous in nature. The most frequent seats of tuber- 
culosis are the lung, the intestinal tract, the lymph- 
atic glands, the serous membranes, the bones, the 
skin, the testicle, the epididymis, the brain, the 
fallopian tubes, the uterus, and the spleen. 
Tuberculosis is very frequent in the lower animals, 
attacking especially the domestic herbivora and 
fowls and wild animals kept in captivity. In cat- 
tle the lesions take the form of nodes and con- 
glomerates, which, on serous membranes, may be 
pedunculated (pearl disease). Histologically, 
there is in bovine tuberculosis a greater tendency 
to the formation of fibrous tissue than in the 
human form. The symptoms of tuberculosis 
vary with the localization of the disease. 
A few general phenomena are common to nearly 
all forms-viz., emaciation, loss of strength, 
anemia, fever, and sweats. Amyloid degeneration 
may occur in various organs when the disease is 
associated with prolonged suppuration. In the 
diagnosis of tuberculosis the demonstration of the 
presence of the bacillus is of the highest import- 
ance. 
TUBERCULOSIS, ACUTE MILIARY (Diffuse 
General Tuberculosis).-An acute and rapid form of 
tuberculosis in which the tubercle bacilli are dis- 
tributed throughout the entire system without 
seeming predilection for any special organ. 
It generally occurs in persons between 12 and 
20 years of age. 
Three varieties are observed (1) general infec- 
tion; (2) general infection with pulmonary symp- 
toms; (3) general infection with cerebral and 
spinal symptoms. 
Etiology.-It arises most commonly from a 
caseating focus in some portion of the body- 
especially in a lung or a lymphatic gland-which 
breaks down, distributing the bacilli to other parts 
of the system by the blood current. The natural 
defenders of the body-the leukocytes, serum, 
and internal secretions-are thus overpowered 
before a reactionary force sets in. Typhoid fever, 
la grippe, or any disease that lowers the vitality 
may aid in causing the onset. 
Pathology.-All the organs are involved, and 
contain small, miliary, discrete tubercles resemb- 
ling mustard seed. They are very abundant in 
the lungs, brain, and may be detected on the 
choroid or retina by means of an ophthalmoscope. 
Symptoms.-The general or typhoid form of 
acute tuberculosis is very often mistaken for 
typhoid fever. The onset usually lasts a few 
days or weeks, with loss of flesh and strength, 
night-sweats, slight fever, especially in afternoon, 
cough, rapid respiration, feeble pulse, flushed 
cheeks, and, later, delirium and stupor. 
Instead of the regular diurnal variation of tem- 
perature it may be very irregular, jumping sud- 
denly from 99° to 104° F., marked by rapid delir- 
ium, and possibly convulsions. The general symp- 
toms depend upon the organs mainly involved. TUBERCULOSIS, PULMONARY 
TUBERCULOSIS, OCULAR 
Focus of Disease in the Lungs. Phthisis Florida, 
Galloping Consumption.-There are two forms: 
(1) the lobar form of miliary tuberculosis follow- 
ing chronic bronchitis, chronic pulmonary tuber- 
culosis, whooping cough, measles, etc.; (2) pneu- 
monic or bronchopneumonic phthisis. There are 
a severe cough with an acute pain in the side, 
accompanied by a purulent expectoration, often 
tinged with blood; intense dyspnea; cyanosis; 
subcrepitant rales over the basis of the lungs; the 
lungs may give a normal note on percussion except 
over the seat of focus, which is seldom found. 
Tubercles may be found in the choroid. 
Focus of Disease in the Meninges. Tuberculous, 
Meningitis.-There are intense headache, high 
fever, delirium, convulsions, stupor, coma, irregu- 
lar pupils, local paralysis, irregular, slow pulse, 
and other symptoms of inflammation of this tissue. 
See Meningitis, (Tuberculous). 
Focus of Disease in the Intestines or Peritoneum. 
-There are intense pain over the affected area, 
tympanites, sudamina, harsh, dry skin, diarrhea, 
disturbed digestion, and dilated pupils. 
Diagnosis.-Tubercle bacilli are often found in 
the blood therefore it should be examined in 
doubtful cases. 
was formerly supposed. The consensus of opinion 
to-day seems to be that tuberculin (g. v.) is of 
decided value not only in the diagnosis but also in 
the treatment of tuberculosis of the eye. For a 
positive diagnosis a local reaction must be ob- 
tained with the tuberculin test. If two tests are 
negative, tuberculosis can be excluded with reason- 
able probability. According to Darier, a violent 
local reaction in the eye may be controlled by 
guaiacol injections (1 to 2 percent) subconjunc- 
tivally. If the reaction is positive tuberculin 
injections, forced feeding, rest, fresh air, etc., 
should be instituted at once. If in 2 to 3 months, 
no decided improvement is noticed, the human 
tuberculin should be supplanted by the bovine 
strain as a mixture of the two should be sub- 
stituted, for the bovine strain may be the agent 
of infection. If the eye disease is secondary to 
glandular infection the bovine strain should be 
used; if secondary to pulmonary infection, the 
human is generally indicated. 
As adjuvant to the tuberculin injections, Darier 
advocates the use of guaiacol in inunctions or 
subconjunctival injections, the guaiacol being 
preferable in the form of the cacodylate. See 
special headings: Conjunctivitis, Cornea, Iri- 
tis, etc. 
TUBERCULOSIS, PULMONARY (Phthisis).-A 
specific infectious disease, due to the tubercle 
bacillus; characterized by the formation of tuber- 
cles in the lungs, which have a tendency to undergo 
necrosis; and manifested clinically by dyspnea, 
progressive loss of flesh and strength, night- 
sweats, hemoptysis, evening rise of temperature, 
and the expectoration of sputum containing 
tubercle bacilli. 
Chronic Ulcerative Phthisis. Symptoms and 
Signs of the Early Stage. Subjective Symp- 
toms.-(1) Progressive weakness and emaciation 
without apparent cause; (2) nocturnal sweats; 
(3) cough, especially in the morning, with 
expectoration of a whitish or yellowish mucus 
often tinged with blood (hemoptysis); (4) morn- 
ing nausea; (5) local chest pains or tightness across 
affected area; (6) dyspnea; and (7) laryngitis. 
Objective Symptoms.-(1) Diminished expansion 
over the affected area; (2) slightly increased tactile 
fremitus; (3) impaired resonance on percussion; 
(4) inspiration harsh and high pitched, and 
expiration prolonged; frequently "cogged-wheel" 
respiration; (5) exaggerated vocal resonance; (6) 
presence of mucous rales (often subcrepitant) at 
the apices of the lungs, sometimes posteriorly 
over base of lungs, and best heard when the patient 
coughs; (7) afternoon rise of temperature, with 
flushed face, usually after 4 o'clock; (8) a rather 
rapid and feeble pulse; and (9) generally the 
appearance of tubercle bacilli in the sputum. 
Symptoms of the Late Stage.-The symptoms 
of the early stage exaggerated: Bacilli more 
abundant, the weakness and emaciation become 
more profound, night-sweats excessive, higher 
temperature and hectic symptoms, diarrhea, 
mucus often greenish, containing small, num- 
mular lumps, cheesy in character, and containing 
many bacilli. 
Acute General Tuber- 
culosis. 
1. Epistaxis not com- 
mon. 
2. Irregular tempera- 
ture with rapid 
exacerbations. 
3. Rash infrequent. 
4. Hurried respiration, 
cyanosis, dyspnea. 
5. Moist subcrepitant 
rales. 
6. Intestinal hemor- 
rhage rare. 
7. Tubercles often 
present in menin- 
geal variety. 
8. No Widal reaction. 
Typhoid Fever. 
1. Epistaxis and diar- 
rhea. 
2. Temperature shows 
a regular diurnal 
variation. 
3. Rose-red spots on 
abdomen. 
4. Respiratory rhythm 
regular. 
5. Dry rales, sonorous 
and sibilant. 
6. Intestinal hemor- 
rhage common. 
7. No tubercles on 
retina or choroid. 
8. Widal reaction. 
Typhoid fever is generally more protracted in 
duration and there is a leukopenia, while in acute 
tuberculosis upon the incidence of mixed infec- 
tion there is a leukocytosis. It is differentiated 
from intermittent fever by the temperature, ab- 
sence of hematozoon of malaria, and negative 
therapeutic test. 
Prognosis.-The disease always terminates 
fatally. 
Treatment is purely symptomatic. If the 
meninges are involved, excruciating pain must be 
combated by hypodermics of morphin, 1/4 grain 
every 3 or 4 hours. A combination of bromid of 
potassium (30 grains) and morphin (1/4 grain) may 
be given to produce sleep. In all varieties a light, 
nutritious diet should be given. 
TUBERCULOSIS, OCULAR.-Since the employ- 
ment of the tuberculin tests, ocular tuberculosis 
has been found to be much more common than TUBERCULOSIS, PULMONARY 
TUBERCULOSIS, PULMONARY 
Predisposing Causes.- 
1. Hereditary tendency is probably the most 
potent etiologic factor in the determination of 
tuberculosis. A phthisical chest may be thus 
inherited. 
2. Sequel of certain diseases is the next most 
common cause. Of predisposing diseases may 
be mentioned pnuemonia, typhoid fever, influenza, 
bronchitis, asthma, pleurisy, diabetes, and cir- 
rhosis of the liver. 
3. Occupations, such as coal-mining, glass- 
workers, mattress-makers, stone-cutters, street- 
sweepers, and close confinement in shops. 
4. Improper habits, such as from alcohol, neglect 
of proper amount of food and sleep, exposure, 
dverstudy, and sedentary habits. 
5. Residence in a low, damp, ill-ventilated, 
imperfectly drained, dusty locality; sleeping with 
a person suffering from tuberculosis. 
6. Age.-From 20 to 35 is the period of life at 
which the disease is most often manifested. 
7. Cold climate is a predisposing factor. 
Method of Entrance of Tubercle Bacillus into the 
System.-(1) Respiratory tract, as from inhalation 
of dust which carries the bacilli; (2) Gastrointestinal 
tract, as from infected milk (common in children); 
(3) Inoculation; (4) Direct parental transmission 
through the placenta (very rare). 
Pathology.-There is no doubt some underlying 
condition of the system that the eye has not been 
able to perceive, or some chemic change produced 
in the fluids and tissues of the body that causes 
certain foci of least resistance, and renders the af- 
fected parts vulnerable to the attack by the tuber- 
cle bacillus. When the bacilli come in contact 
with such tissue, they are distributed throughout 
these foci by the lymph, blood, wandering con- 
nective-tissue cells, and leukocytes. The charac- 
teristic inflammatory process is usually a slow 
one, and the dominant action tends toward de- 
generation, with but a slight apparent attempt 
to form new tissue from the newly formed granula- 
tion cells. 
The characteristic lesion produced by the bacil- 
lus of tuberculosis is a tubercle, which is a minute 
nodule, often the size of a millet seed, grayish or 
whitish in color, and quite translucent. If a sec- 
tion is made of a tubercle, it will be seen to have a 
certain arrangement: in the center of the nodule 
are a few large cells, with many nuclei (20 to 
30), and two or three times the size of the sur- 
rounding granulation cells, called "giant cells," 
in which are lodged tubercle bacilli. The central 
portion of a tubercle has very few cells. Im- 
mediately surrounding the central portion of the 
tubercle are arranged a considerable number 
of epithelioid cells (wandering connective-tissue 
cells), and beyond them concentrically are found 
an abundance of small, round, granulation cells, 
between which are densely packed myriads of 
bacilli and many leukocytes. A few giant cells 
may be seen scattered throughout this area. 
Guiteras compares the arrangement of cells 
from within outward to a "raked field." Cheesy 
necrosis, with subsequent liquefaction, begins in 
the center of the tubercle, usually in the giant cells 
and spreads peripherally. If calcification sets up 
in the area of granulation cells, there will be 
spontaneous recovery. Usually septic organisms 
gain entrance into the tubercle, causing rapid 
fatty degeneration and excessive ulceration of the 
surrounding tissues, with the development of 
cavities. The blood changes show a moderate 
degree of anemia. 
Diagnosis rests upon the physical signs and the 
presence of tubercle bacilli in the sputum. 
Inspection.-The chest is long and flat, the sub- 
clavicular region depressed, and the clavicles are 
very prominent. The angles of the scapuke bulge, 
and the ribs are at an oblique direction down- 
ward from the sternum. There is diminished 
expansion over the affected area. 
Palpation shows increased vocal fremitus. 
Percussion shows impaired resonance or dulness 
below the clavicle and between the lower border 
of the scapulae. If a cavity is present, a tympanitic 
note will be obtained. 
Auscultation.-The inspiration is harsh, high 
pitched; the expiration prolonged and harsh; 
cogged-wheel respiration. There is increased 
vocal resonance. There are mucous rales over 
the apices of the lungs anteriorly, and over 
the base of the lungs posteriorly. Pectoriloquy 
with large rales and amphoric breathing may be 
detected if there is a cavity. 
In doubtful cases the tuberculin test may be 
resorted to. 
Krause claims to be able to make a diagnosis of 
early tuberculosis especially in children by means of 
the fluoroscope or radiography before it can be 
made by any other method. 
Acute Phthisis.-A form of phthisis clinically 
resembling pneumonia in its early stages, usually 
terminating in death within a few weeks. 
Fibroid Phthisis.-A slow form of phthisis in 
which the physical signs and symptoms gradually 
develop. 
Complications of All Forms of Phthisis.-Pul- 
monary hemorrhage, pneumonia, pleurisy, diarrhea, 
extension to other organs, as the larynx, brain, 
kidneys, liver, peritoneum. 
Distribution of Tubercles in the Body.-(1) 
Lungs (adult); (2) Lymph-glands, bones, and 
joints (in children); (3) intestines; (4) peritoneum; 
(5) kidneys; (6) brain; (7) spleen; (8) liver; (9) 
generative organs; (10) pericardium; (11) heart. 
Prognosis is in the main unfavorable, although 
under proper treatment, change of climate, and 
other favorable conditions life may be prolonged 
for years. 
Treatment.-In the treatment of pulmonary 
tuberculosis the first and most essential element 
is confidence on the part of the physician in the 
resources of his art. The prognosis is yearly becom- 
ing more favorable as the probability of recovery 
under good management is better realized, and 
the principles of treatment become better under- 
stood. It is, moreover, necessary for the attendant 
to be assiduous and minute in his care of the details 
of treatment, for upon these depends success or 
failure. Each patient must be an individual 
study, and the general plan should be modified TUBERCULOSIS, PULMONARY 
TUBERCULOSIS, PULMONARY 
in accordance with his reaction to remedies, and 
with the progress of the case. It is necessary 
to dwell upon these points, for they are often 
neglected. 
Of the remedies useful in the management of 
pulmonary tuberculosis drugs occupy a distinctly 
secondary position. The chief reliance is to be 
placed upon hygienic measures-the scientific 
use of air, sunlight, water, food, rest, exercise, etc.- 
that will improve nutrition and increase vital 
resistance. Especially does this apply to the 
preventive regime that should be instituted from 
birth, if possible, in the case of those specially 
liable to the disease by heredity, whether the 
ancestral taint be tuberculosis itself or some other 
condition-for example, syphilis or carcinoma- 
likely to produce hypotrophy in the offspring. 
The patient's daily life must, therefore, be con- 
trolled as far as circumstances will permit. The 
treatment of tuberculosis among the well-to-do is 
thus both easier and more successful than among 
the poor. For both classes sanatoriums are often 
to be preferred; but the personal, mental, and 
moral equation must be considered in deciding 
this. 
The principal subjects of care are: 
1. Place of residence, including both climate 
and dwelling-house. 
2. Clothing. 
3. Rest and exercise in general; including 
exposure to light and air, occupations and amuse- 
ments. 
4. Food. 
5. The use of water, internally and externally. 
6. Special pulmonary exercise, including the 
use of air at modified pressure. 
7. The regulation of secretions and excretions. 
8. The use of drugs (1) to improve general nutri- 
tion, (2) to improve special functions, (3) to antag- 
onize the tuberculous processes, (4) to meet 
special indications. 
These may first be considered in a general way, 
and later the modifications for special cases and 
stages of the disease may be indicated. 
Place of Residence.-The subject of climate is 
more fully considered under Climatology (q. v.). 
Climatic treatment is desirable whenever possible. 
In many cases it is best to find a place where the 
patient can spend his life, and follow his vocation. 
Whether for this, or for temporary sojourn until 
health is regained, the place should be one where 
the patient can be out-of-doors most of the time 
and at all seasons of the year; though moderate 
change of location with seasons is sometimes 
beneficial for the sake of physical and mental 
variety. In many cases, especially in early 
tuberculosis, and in cases characterized by per- 
sistent high temperature, an ocean voyage, pref- 
erably of not less than a month's duration is the 
best therapeutic measure available. 
With reference to climate the majority of pa- 
tients fall into one of two principal classes-the 
robust and those needing protection. This may 
depend upon original constitution or upon the type 
and stage of the disease. 
As a rule, the robust are benefited by cold and 
altitude, and some, in addition, by a certain degree 
of hardship-roughing it, as in lumbermen's 
camps and upon cattle-ranches. Good judgment 
is needed in the gradual increase of hardship, as 
sudden change from coddling to the opposite 
extreme would be likely to prove fatal. Among 
counterindications to altitude that need to be 
insisted on are (1) readiness of disturbance of 
cardiovascular balance, (2) cardiac weakness, (3) 
small size of heart, (4) neurotic or erethistic tem- 
perament, (5) persistent high temperature. 
Those that need protection do better, as a rule, 
in warm or equable and comparatively dry places 
at the sea-level or but little elevated. Between 
these classes is a third to whom cold and moderate 
elevation, say not over 2000 feet, proves stimulat- 
ing and restorative. In all cases purity and 
reasonable dryness of the atmosphere is a desidera- 
tum. The best of judgment is necessary in the 
choice of climate, and routine direction of every 
patient to one place or one class of places is pro- 
ductive of much harm. When patients cannot 
go far from home, something may still be done to 
improve their surroundings. Thus, both for air 
and light, the country is preferable to the city, a 
wide street to a narrow one, a detached house to 
one shut in on both sides. A hillside is better than 
a valley, a dry, sandy soil than moist clay. When 
the subsoil water approaches within 6 feet of the 
floor of the cellar, the first floor of the house should 
be sufficiently elevated; a cemented cellar is 
desirable. The air of the house should not be too 
dry, as air devoid of moisture provokes cough, and 
may induce hemorrhage. It should be constantly 
renewed, preferably through open windows. 
Other means of ventilation should be provided for 
bad weather. The temperature should be equable 
and not too warm. Except when special indica- 
tions require it otherwise, 65° F. is a desirable 
standard. The temperature of the bedroom, 
which should be occupied only at night, and by no 
other person, should rarely exceed 60° F. The 
bedroom should have a high ceiling, and be as large 
and as sunny as possible, 1500 cubic feet of air-space 
being the minimum. There should be several 
windows for constant ventilation during the day. 
If there is a fire in the room, it should be in an open 
grate. The furniture should be as simple as 
possible. Electric light is preferable to any other, 
and lamp or candle to coal-gas. 
When there is no counterindication, at least one 
window should be open at night, the patient being 
protected from draft. 
The clothing should be warm, but light, loose, 
and not oppressive. As far as possible it should be of 
open texture, and should be changed with climate, 
seasons, and weather. Woolen or silk underwear, 
or a mixture of wool and cotton so arranged as to 
absorb the perspiration quickly and as quickly 
yield it to the outer air, should be worn both 
winter and summer. Protection is needed for the 
entire body, including the extremities; and the 
stockings are as important as the undershirt. 
Corsets, close-fitting waists, low-bosomed gowns, 
and tight belts are to be forbidden. Close-fitting 
scarfs, fur boas, and the like, around the neck are TUBERCULOSIS, PULMONARY 
TUBERCULOSIS, PULMONARY 
harmful, as are wadded flannel and buckskin 
" chest protectors," plasters, and similar abomina- 
tions so often discovered upon stripping the 
patient for examination. In our northern climates 
extra wadding in and between the shoulders of the 
coat worn in the late fall and early spring, and a 
cape to the winter overcoat are often desirable. 
Sealskin and other heavy wraps are to be avoided. 
Patients with weak circulation should be well 
wrapped when driving, and when necessary, should 
use muffs and foot-warmers. Waterproof outer 
garments are in some cases a less evil than a wet- 
ting; they should be removed immediately on 
going indoors. As little clothing as possible 
should be worn in bed, the bed-covers being varied 
as necessary. A long woolen night-gown of light 
weight, or a "union" suit of the same material, is 
the best in most cases. Hair mattresses with 
spring supports are best. Metal is better than 
wood for the bedstead, being more easily cleansed. 
Night-dress, underwear, and bed-covers must be 
changed even more frequently than ordinary 
cleanliness requires. 
Rest and exercise must be considered together, 
the usual fault of physicians and patients alike 
being to insist too much upon one or the other. 
Individualization, the key to successful treatment 
generally, is in this matter specially necessary. 
When there is as yet no demonstrable lesion, and 
one merely suspects tuberculosis, a weak patient- 
especially a young, anemic girl-should be put to 
bed, if possible, and the Weir Mitchell "rest cure," 
or some modification-with massage and electric 
applications, and perhaps a daily drive or other 
nonfatiguing outing-be instituted. Later, and, 
on the other hand, from the beginning in a fairly 
robust person, active physical exercise should be 
gradually begun and increased, and preferably 
such as will keep the patient out-of-doors. Sports 
of various kinds, especially those which gently 
exercise the chest muscles, and afford pleasant 
diversion to the mind; systematic gymnastics, 
especially of the respiratory muscles; walking, 
bicycling, horseback riding, and even driving in 
an open carriage, are to be recommended; always 
in moderation, and according to the patient's 
condition. When there are extensive lesions, 
especially if there is constant and decided eleva- 
tion of temperature, rest is absolutely necessary; 
and exercise should be the least and gentlest. It 
is not always necessary to rest indoors; a hammock 
swung in sun or shade, according to season and 
climate, a steamer-chair on porch or deck, are 
frequently preferable to couch and bedroom or 
cabin. As the patient improves, the period of 
rest is to be diminished, and exercise is to be 
quantitatively and qualitatively increased. Be- 
sides these illustrative extremes (and, indeed, in 
every case, as it passes through its stages of 
betterment or deterioration), there are many 
varieties of physical and mental conditions to 
which the physician's advice as to judicious alter- 
nation of rest and exercise must be adapted. Thus, 
when a patient with moderate lesions and no fever 
is unable to leave the city, a good plan of outdoor 
exercise is to have him walk slowly along the street 
in the opposite direction to the car-track, so that 
before fatigue occurs he may ride home. Or he 
may ride to a park (such as Fairmount in Phila- 
delphia), and there walk and sit, again walk and 
sit, and, finally, after an hour or so, ride home. In 
many cases where the character of the country 
permits, ascents proportionate to the age and 
strength of the patient may be prescribed. They 
should be made with slow and measured steps and 
rests by the way. To expand the lungs while 
climbing, the elbows may be approximated behind 
the back, and a walking-stick may be supported 
between them. Whether walking on a level or 
climbing, the patient should be instructed to 
breathe deeply and slowly. Whether with the 
weak or the comparatively strong, fatigue is 
always to be avoided; exercise, therefore, should 
be instituted in a mild form and gradually 
increased. 
Open-air treatment is of decided value. Ex- 
posure to open air and to sunlight should be as 
frequent, as long, and as thorough as the climate, 
season, weather, and patient's condition and 
endurance permit. The roof or back yard may 
be used on pleasant days. Even if circumstances 
compel housing, the endeavor should be made to 
get the sun and fresh air into the room where the 
patient sits or reclines. He should rest, warmly 
wrapped, before the open window. At night the 
windows should be kept open. -The importance 
of this treatment cannot be too often reiterated. 
In choosing an occupation for one thought to be 
liable to tuberculosis, or in the management of a 
patient already showing symptoms of the disease, 
the desirability of open-air life must be borne in 
mind. Many persons recover through change of 
business. Quite in point is Benjamin Franklin's 
celebrated instance of the man who contracted 
consumption while a shoemaker, and recovered 
while riding as post-boy between New York and 
the Connecticut River (about 140 miles) in all 
seasons and weathers. Most patients are kept 
indoors too much on account of weather. While 
care is necessary, it is best to be out whenever 
possible. 
Amusement is quite as important as occupation, 
and requires equally good judgment. When the 
patient has tastes and means for a pleasant avoca- 
tion, his desire should be gratified. In any case 
the endeavor should be made to divert the mind 
from self by reading, music, games, theater, con- 
cert, and lecture (when this does not involve too 
long a stay in an overcrowded hall), or whatever 
means are available. Undue excitement, how- 
ever, is to be avoided-. 
Food is to be carefully chosen with due con- 
sideration of the habits and digestive capacity of 
the patient. Nutrition, nutrition, nutrition, is 
the essential of treatment; and food the essential 
of nutrition. Two mistakes are to be avoided- 
overfeeding and underfeeding. Often the patient 
lacks appetite, but is able to digest and assimilate 
much more food than is required in health. In 
such cases it is wise to feed up to the limit of 
digestive capacity, and for this purpose twice daily, 
after a preliminary lavage with a warm solution of TUBERCULOSIS, PULMONARY 
TUBERCULOSIS, PULMONARY 
sodium bicarbonate (1 dram to 1 pint), about a 
quart of fully peptonized milk, with one or two 
eggs, an ounce of beef-powder, 30 drops of dilute 
hydrochloric acid, and 5 or 10 grains of pepsin may 
be introduced through the stomach-tube. The 
ingredients are to be thoroughly mixed, and the 
temperature of the mixture should be about 100° 
F. In addition to the gavage, the patient may be 
allowed to eat a midday meal of such permissible 
food as pleases his palate. Other patients will need 
only to be encouraged to eat sufficient food, and 
gavage will be unnecessary. In other cases the 
digestive capacity and the exercise taken become 
important factors in permitting the amount of 
food given to be increased. The assimilative 
power is impaired, and until, by proper manage- 
ment, this has been restored, it will be necessary to 
restrict the quantity and kinds of food. As a 
general rule, subject to modification in individual 
cases, patients having good prospects of recovery 
or partial recovery should be fed as bountifully as 
possible; while those in the later stages, with the 
end nearing, especially when active exercise has 
been interdicted, should not be given large quan- 
tities of food. In the average case the meal, 
should be comparatively frequent-say 6 per diems 
at intervals of about 3 hours. At three of these 
meals there should be taken as much as one in good 
health ordinarily eats. The others may consist 
of a plate of soup or a glass of milk or of cream or 
a half-dozen oysters or a sweetbread or a squab or 
something similar. It is often well to drink a 
glass of hot milk just before going to bed; and in 
some cases milk or a liquid preparation of so-called 
peptones or a glass of a good wine of coca should 
be at hand to be taken if the patient awakes during 
the night. A half-hour before meals 1/2 of a pint 
or a pint of hot water is often of use in preparing 
the gastric mucous membrane for the reception 
and disposition of the food. Simplicity in diet is 
necessary. Nitrogenous and fatty elements should 
predominate, sugars and starches be reduced to a 
minimum. 
Cod-liver oil, plain, or emulsionized with the aid 
of pancreatin, is one of the best of fatty foods. It 
may be given in doses of 1/2 of an ounce or less 
after meals. In some cases beef or mutton fat, but- 
ter, olive oil, and the like, serve equally well, 
and, being utilized in the ordinary way, seem less 
like medicine. Milk, preferably hot, is to be 
taken freely; if possible, a quart and a pint of milk 
and a pint of cream daily. Koumiss, kefyr, and 
the like may be substituted for plain milk or alter- 
nated with it. Soups, such as bouillon, oyster 
broth, clam broth, mutton broth, beef broth, 
turtle soup, barley, rice, bean and pea soups and 
purges, celery broth made with milk and thickened, 
are useful. Beef, underdone, roast or broiled; 
mutton or lamb roast, or broiled chops; sweet- 
bread; brain; poultry, broiled, roast, or stewed; 
nearly all kinds of game; fresh fish; salt codfish; 
salt mackerel; eggs, steamed, boiled, poached, 
beat up with milk, should be the principal articles 
of diet. Nothing should be fried. The green 
vegetables-lettuce, spinach, asparagus, water- 
cress, and the like-are of great service; as are, 
likewise, the legumens-peas, beans, lentils, etc. 
Fresh fruits of all kinds are to be freely used in the 
absence of special counterindication. Of starchy 
foods, rice, well cooked, and occasionally sago, 
tapioca, etc., are the best. Potatoes, turnips, 
carrots, beets, and other starchy and sugary roots 
and tubers are to be avoided altogether or used 
very sparingly, for occasional variety. The infre- 
quent potato should be "roasted in the jacket" 
until it becomes ready to fall into powder when 
opened; or, if necessary, "twice baked." Other 
desirable vegetables are tomatoes, onions, and 
celery. Cereals-hominy, oatmeal, cracked wheat 
and similar preparations-may be used in modera- 
tion if well digested. Bread should be reduced to 
the minimum consistent with comfort-toast, 
zwieback, and pulled bread being preferable to 
ordinary bread. Hot bread, cakes, pies, pastry, 
sweetmeats, made dishes, rich gravies, crabs, 
lobsters, and, among meats, pork and veal are to 
be strictly avoided. 
The best beverage is water, to be taken freely; 
the purer the better. Mineral waters offer no 
special advantage unless needed as laxatives or 
diuretics. In some cases alcohol is of the highest 
use, in others useless, and in others harmful. It 
should not be given as a routine. When given, 
it should be used in comparatively large quantities 
-from 4 to 8 ounces of good whisky daily. When 
the patient is taking sufficient other food, the 
heart is acting well, and the digestion is good, 
alcohol is usually unnecessary. When there are 
fever, impaired appetite, poor digestion, and feeble 
action of the heart, alcohol usually helps tempo- 
rarily. While by no means advocating this plan, 
reference may be made to three cases of remark- 
able recovery-i. e., restoration to good health 
of patients with decided pulmonary lesions- 
upon the old treatment of whisky and cod-liver 
oil-the quantities ordered having been " as much 
as you can stand." The period over which the 
treatment extended in these cases varied from a 
few months to several years. 
Water is to be used freely both internally and 
externally. Not only the drinking of hot water 
before meals, but, if necessary, lavage of stomach 
and intestines with physiologic saline solution or 
some alkaline detergent solution of about the same 
specific gravity is to be practised in order to keep 
the alimentary canal clean, as free as possible of 
ptomains and other toxins, and the mucous mem- 
brane active. In addition pure, cold water, car- 
bonated or still, as may be most palatable, is to be 
imbibed freely between meals; and may also be 
taken with meals, in moderate quantity, if prefer- 
red. Wine and water (claret or Burgundy) is 
better than plain water with meals. 
Hydrotherapy is of the greatest importance not 
only as a curative, but also as a prophylactic 
measure. 
Water should also be freely used externally, not 
merely for cleanliness but as a direct stimulant to 
the skin and its vessels, and immediately to circula- 
tion, respiration, and general nutrition. Accord- 
ing to the patient's age, temperament, and 
strength, the stage of the disease, the condition TUBERCULOSIS, PULMONARY 
TUBERCULOSIS, PULMONARY 
of the heart and vessels, the individual reaction, 
the climate, season, and weather, various hydro- 
therapeutic measures are useful. For details, 
treatises on hydrotherapy should be consulted. As 
a prophylactic measure cool or cold sponging on 
rising in the morning is generally applicable. 
Those who react well may substitute or add a 
gentle shower bath or douche-at first for 20 or 30 
seconds, later for a minute or more. This is to 
be followed by forcible, dry friction; and the patient 
having dressed and having swallowed, not hastily, 
a glass of hot milk, should take a walk, not long 
enough to cause fatigue, and then return for 
breakfast. In unpropitious weather, indoor ex- 
ercise,- gradually increased in activity, may be 
substituted. > 
Delicate and sensitive persons not inured to cold 
bathing must be accustomed to it gradually, 
tepid, water being used at first. In every case 
the physician . should prescribe the temperature 
of the water and the details and duration of 
the bath, douche, or other application, with 
the .same care that he gives to the dosage of 
medicine. 
Counterirritation is sometimes useful in the early 
stages of pulmonary tuberculosis, and especially 
when there is softening. Cantharidal collodion 
or a mixture .of tincture of iodin, croton oil, ether, 
a,nd collodion may be employed. The best plan 
is to irritate successive small portions of the skin 
oyer the seat of lesion, allowing one spot to heal 
before the next application is made. 
Pneumotherapy, or the use of air at modified 
pressures, is among the most important, as it is 
the most neglected, of our means of defense against 
pulmonary tpbergulosis. The literature of the 
subject should be carefully studied by every 
physician. In many cases the use of appropriate 
apparatus under the physician's direction will 
obviate the necessity of seeking a change of climate. 
There; are two forms in. which condensed and 
rarefied air may be utilized. These have been 
termed the absolute and the differential methods. 
The first is carried, out by the use of pneumatic 
chambers modeled after the diving bell, the 
first of which was constructed for Tabarie in 1838. 
The patient remains for an hour or more in air 
gradually raised to a pressure far exceeding the 
normal (from 1 1/2 to 2 atmospheres), and then 
gradually lowered. Rarefied atmospheres are 
theoretically useful, but have not been Used in 
medicine in these chambers. The disadvantage 
of this method is that its use is limited to certain 
resorts. The differential method is carried out by 
apparatus of two different types. In one, the 
p.atients remain in the ordinary atmosphere and 
inhale from or exhale into (or both) cylinders con- 
taining condensed or rarefied air. In the other, 
patients enter an apparatus in which the air about 
them is condensed or rarefied, while they inhale 
from and exhale into the ordinary air. The type 
of instruments of the first class is the gasometer 
of Waldenburg-the modification of S. Solis-Cohen 
being the most convenient for use at the patient's 
home. The type of instruments of the second 
class is the pneumatic tub of Hauke; the 
pneumatic cabinet of Williams being the most 
elaborate. 
The physiologic and therapeutic effects of the 
two types of instruments do not differ; the ques- 
tions to be considered being merely of expense 
and mechanic convenience, While the pneumatic 
cabinet is theoretically capable of the same varia- 
tion in use as the gasometers, in practice it is 
impossible to alter its pressure rhythmically with 
the patient's respiration; hence the air it contains 
must be either rarefied or condensed during an 
entire sitting; the patient thus both inhaling from 
and exhaling into air relatively higher or lower 
than that surrounding him. The most common 
use is to rarefy the air of the cabinet, and the 
patient thus continuously respires relatively con- 
densed air. 
In the gasometer instruments any of the fol- 
lowing 8 modifications are perfectly practicable: 
Inhalation from 
1. Condensed air. 
2. Condensed air. 
3. Condensed air. 
4. Rarefied air. 
5. Rarefied air. 
6. Rarefied air. 
7. Unaltered atmosphere. 
8. Unaltered atmosphere. 
Exhalation into 
Unaltered atmosphere. 
Condensed air. 
Rarefied air. 
Unaltered atmosphere. 
Condensed air. 
Rarefied air. 
Rarefied air. 
Condensed air. 
In pulmonary tuberculosis the expedients 
numbered 1, 2, and 3 are those employed, and 
chiefly 1 and 3. The most useful is generally 
3; which fact alone serves to give this method 
the preference over the pneumatic cabinet. 
If desired, the air inhaled, which is drawn from 
out-of-doors, and filtered through cotton on its 
way to the cylinder, may be artificially cooled, 
warmed, dried, or moistened. The air may be 
impregnated with the vapor of any medicinal 
substance, by passing it through a solution in a 
wash-bottle, by suspending in the condensation 
cylinder a vial or a sponge containing the drug, or 
by inserting a sponge or cotton wad, appropriately 
nloistened, in the mouth-piece. The pressures 
(positive or negative) employed, which are to be 
gradually increased as the case progresses, range 
from 1/75 to 1/30 of an atmosphere (1/5 to 1/2 
pound to the square inch); and are regulated by 
weights or counterweights as condensation or 
rarefaction is desired. The inhalations and ex- 
halations are to be made as slowly and per- 
fectly as possible, the rate of respiration being 
reduced to 10 or less a minute, if possible; the 
volume of air inhaled or exhaled being brought 
up to 200, 250, 300, or even 400, cubic inches as 
recovery progresses. From 5 to 20 minutes 
continuous respiration is followed by a rest of the 
same length, and a repetition of the process. 
The patient should stand, if able to; the clothing 
should be loosened, outer garments being re- 
moved, and, if necessary, the physician or an 
attendant should assist respiration by pushing the 
patient's shoulders back during inspiration, and 
pressing the arms against the sides Of the chest 
during expiration. The treatment is time con- 
suming and requires intelligent care and super- TUBERCULOSIS, PULMONARY 
TUBERCULOSIS, PULMONARY 
vision; but should not therefore be omitted. 
When patients can afford to buy or rent an ap- 
paratus for use in their own homes, a member of the 
family or a nurse can readily be instructed in its 
use. It is worth all the drugs in the Pharmacopeia 
as a therapeutic measure in pulmonary tuberculosis. 
Briefly, inhalation of condensed air produces the 
following effects: Diminution of muscular effort; 
increased dilatation of alveoli; increased volume 
and penetrating power of tidal air; consequent 
increase of gaseous exchange and volume of ex- 
pired air; increase of volume of pulmonary circula- 
tion; increased absorption of oxygen; increased 
peripheral circulation; increased metabolism. 
There result: Diminished frequency of respiration, 
increased expansion and ventilation, with great 
increase of vital capacity; diminished frequency, 
with increased force of heart's action and increased 
fulness of the pulse. 
Exhalation into rarefied air produces the follow- 
ing effects: Contraction of the thorax is facilitated; 
expiration is made more complete; subsequent 
inspiration is easier and deeper; pulmonary con- 
gestion is diminished; the heart is more thoroughly 
emptied, and diastole is facilitated. The com- 
bination of these procedures is, therefore, an effect- 
ive means of pulmonary ventilation and of reliev- 
ing local stases. It acts as a stimulus and a regu- 
lation to respiration and circulation, and thus 
becomes an effective means of restoring both local 
and general nutrition. The vital capacity of 
patients is permanently increased, especially by 
calling into use portions of lung not fully expanded; 
appetite is improved, and the greater quantities of 
food consumed are oxidized and utilized. Secre- 
tion is stimulated and excretion facilitated. 
Cough and expectoration are at first increased, 
from dislodgement of accumulated materials, 
afterward diminished. Sleep is promoted. 
When there is elevation of temperature to 100° 
F., the method is to be employed only with caution, 
and not at all if the fever is continuous and marked 
local changes are in progress. Active softening 
without fever is also a counterindication. Pneu- 
matic treatment should not be used when there is 
a large cavity with fluid or semifluid contents; 
but dry cavities present no objection. If hemor- 
rhage occurs, inhalation should be intermitted, 
but may be resumed cautiously some tim6 after 
the bleeding has ceased. 
After patients have sufficiently recovered to 
omit the constant use of the apparatus described, 
the good effects may be kept up by use of S. S. 
Cohen's pneumatic resistance valve. By adjust- 
ing the springs as shown upon the scale above each 
valve to one of the figures, 6, 5, 4, 3, there is 
secured a pressure approximately of 1/60, 1/50, 
1/40, or 1/30 of an atmosphere, in resistance to 
inspiration or expiration or both, as desired; that 
is, practically, inspiration of rarefied air and 
expiration into condensed air. The effect is to 
necessitate greater muscular effort in respiration, 
and thus to secure regulated pulmonary gym- 
nastics, with stimulation of circulation. It can- 
not take the place of the other method, but is 
applicable only with patients able to make the 
increased exertion; the gasometer being employed 
when patients need assistance in respiration. It 
is especially applicable as a prophylactic measure 
in the young and fairly robust, who need to be 
given a proper respiratory habit. The inspired air 
may be medicated by placing a few drops of any 
suitable volatile drug or mixture (eucalyptol, 
creosote, chloroform, ethyl iodid, terebene, etc.) 
on cotton in the receiver. _ ; 
Sometimes patients may be induced to respire 
properly through the device of Dr. Ramadge: 
A tube (a section of ordinary "speaking-tube," 
with a proper mouth-piece will answer) about 4 
feet long, with the far end slightly narrowed, which 
is to be placed out of the window every morning 
and noon, while slow, full respiration is practised 
for from 5 to 30 minutes. 
The secretions and excretions are likely to be 
kept in good order by following the plans detailed 
as to clothing, outdoor life, food, rest, exercise, and 
the use of water and of air, but sometimes special 
treatment or medication is temporarily necessary. 
These measures do not differ in principle or method 
from those employed in other affections. Some 
authors recommend, however, the more or less 
constant administration of cardiaiit diuretics, 
such as spartein sulphate. 
Tuberculin Treatment.-After tuberculin was 
discredited as a remedy, its composition became 
the subject of research, with the view of obtaining 
from it a remedial agent free from its toxic con- 
stituents. Von Ruck prepared a purified tuber- 
culin, also an aqueous extract of the bodies of the 
bacilli; and Koch announced his tuberculin-r and 
the new tuberculin, which are emulsions of the 
pulverized bacilli, the latter being made with water 
and glycerin as a menstruum. These preparations 
have been extensively used during the last ten years. 
Denys and Trudeau prefer the unheated bouillon 
filtered free from bacilli. On general principles 
the filtrates or solutions, such as T. O. (Koch's 
old tuberculin) and B. T. of Denys, and T. B. K- 
of B6raneck are safer for the beginner by reason of 
their greater uniformity of dosage and the gener- 
ally milder reaction produced than by the emul- 
sions or vaccines T. R. (tuberculin residuum) and 
B. E. (bacillus emulsion). 
Denys and Trudeau recommend 1/10,000 mg. of 
tuberculin as the initial dose for afebrile cases, 
increasing by 1/10,000 every third or fourth day 
until 1/1000 mg. is reached; then increasing by 
1/1000 till the dose is 1 /100 mg.; then by 1 /100, etc. 
The entire gradation of solutions necessary 
would be-Filtrate, 1 c.c. of this being the final 
dose: , 
Solution in which 1 c.c. =100 mil. 
Solution in which 1 c.c. =10 mil. 
Solution in which 1 c.c. = 1 mil. 
Solution in which 1 c.c. =1/10 mil. 
Solution in which 1 c.c. =1/100 mil. 
Solution in which 1 c.c. =1/1000 mil. 
Solution in which 1 c.c. =1/10,000 mil. 
For febrile patients begin with sol. 1 c.c. = 
1/10,000 mil. (0.1 of this =1/100,000 mil.). TUBERCULOSIS, PULMONARY 
TUBERCULOSIS, PULMONARY 
Begin with .1 and increase .1 every three days. 
For afebrile cases begin with sol. 1 c.c. = 1/1000 
mil. (0.1 of this =1/10,000 mil.). Begin with 
.1 of this and increase .1 at each injection three 
days apart. 
When the solution 1 c.c. = 1/10 mil. is reached, 
it is better to repeat the dose occasionally. 
The intervals are extended when the dose 
becomes 10 mg. or when symptoms of intolerance 
supervene, such as local reaction, soreness, 
anorexia, malaise, loss of weight, pains, increased 
sputum. It is best to allow at least 6 to 10 days 
between the larger doses, 4 days being allowed as 
soon as the solution 1 c.c. = 100 mil. is reached. If 
fever reactions appear, the injections are discon- 
tinued till there have been no symptoms of intol- 
erance for at least 2 days; then the doses are 
decreased (first to 1/2 the previous dose, then in- 
creasing at usual intervals) or kept the same until 
tolerance again exists. 
The course of treatment, as outlined by Denys 
and Trudeau, is 6 to 12 months according to the 
occurrence or absence of reactions. The aim is to 
produce tolerance to as large doses of tuberculin 
as possible by increasing the dose gradually 
(tuberculin immunization). In most instances 
a dose of 1 c.c. can be reached. After a lapse 
of 3 to 6 months a short secondary treatment is 
advised. 
It is advisable to repeat the same dose occasion- 
ally especially when the larger doses are reached, 
the extension of the treatment being advantageous. 
The dilutions which are made with normal salt 
solution containing 1/4 of 1 percent carbolic 
should be made fresh at least every two weeks and 
should be kept in a cool place. 
Injections are best made below the scapula or on 
the upper aspect of the arm-alternating the side 
each time. 
Tuberculous lesions are due to the bovine 
bacillus in some cases rather than the human and 
therefore fin these instances the bovine strain 
produces better results. If no definite improve- 
ment obtains after use of the human for three 
months it is advisable to try the bovine strain or a 
mixture of the two. 
The selection of cases suitable for this treatment 
requires careful consideration of their history and 
present condition. The patients must have good 
nutrition and fairly localized disease without 
extensive ulceration or complications. The results 
of the treatment are most encouraging in chronic 
types of tuberculosis. It is contraindicated in 
acutely progressing tuberculosis, disseminated, 
miliary and pneumonic types, those with extensive 
nephritis, diabetes or cachectic symptoms, and in 
favorable cases during exacerbations with fever or 
when complicated with influenza or other acute 
intercurrent diseases. 
In the cases complicated with chronic mixed 
infections, indication for the treatment can be 
determined only by careful study of the individual. 
Tendency to hemoptysis is a contraindication, but 
bloody sputum due to a mild local reaction is 
nsignificant. Very good results have been ob- 
ained in patients whose disease has become 
arrested by hygienic methods, but who would 
eventually succumb to chronic phthisis. 
Antitubercular Serum Therapy.-No satisfactory 
results have been attained with antitoxic serums 
for tuberculosis in any degree comparable to the 
success with diphtheria antitoxin. It is doubtful 
whether a true antitoxin in the serum of treated 
animals exists, although antibodies have been 
demonstrated. The protracted nature of the 
disease entailing repeated injections of the sera, 
unpleasant consequences may arise due to the 
serum itself. The occasional development of 
symptoms of "serum disease" (urticaria, joint 
pains, collapse), militate against the subcutaneous 
use of serum. 
The principal sera recommended at present are 
those of Maragliano and Marmorek. Of late the 
latter has found favor in doses of 5 to 20 c.c., per 
rectum. The dose of Maragliano's serum is from 
1 to 5 c.c. subcutaneously; also per os or rectum. 
Antistreptococcus serum in mixed infection is of 
doubtful efficiency, although good results are 
claimed in some desperate cases. The rectal 
administration is preferable and safe. 
Bacterial Vaccine Therapy.-The inoculation of 
sterile bacteria prepared according to Wright's 
methods from cultures obtained from the sputum, 
a promising method of treatment for chronic 
mixed infections, is now sub judice. See Vaccine 
Therapy. 
Medication in pulmonary tuberculosis may be 
directed against some symptom, or may be directed 
generally to improving nutrition: i. e., vital 
resistance. Next to cod-liver oil, the most 
efficient drugs are the creosote group and the iodin 
group. 
The creosote group includes creosote, creosote 
carbonate, guaiacol, guaiacol carbonate, guaiacol 
salicylate, guaiacol benzoate, and potassium 
guaiacol sulphonate (known as thiocol). The 
iodin group includes metallic iodin, Lugol's solu- 
tion, arsenic iodid, Donovan's solution, diisobutyl- 
orthocresoliodid (known as europhen), ethyl 
iodid, and iodoform. 
Of good beechwood creosote large doses may be 
given by gradual increment without disordering 
digestion; but many of the commercial prepara- 
tions contain gross impurities, and are unfit for 
internS.1 use. Some patients cannot take large 
doses, or even small doses, of even the best creo- 
sote; in which case one of the substitutes men- 
tioned may be used. Creosotecarbonate (creosotal), 
a syrupy liquid, is even better than creosote and is 
best given in hot milk, and in doses of from 5 to 
60 minims, 3 or 4 times daily. The guaiacol salts 
are tasteless or nearly tasteless powders, and may 
be given as such or in capsule, in doses aggregating 
from 15 to 75 grains daily. Duotal or guaiacol 
carbonate is sometimes better borne than creosotal. 
It is given in doses of 3 to 7 1/2 grains three times 
a day. Beechwood creosote may be given in doses 
of from 1 to 40 minims 3 or 4 times daily. The 
average dose is 10 minims. It is best given in 
milk, about 2 hours after meals. It may be shaken 
up with a tablespoonful of cod-liver oil, which 
some patients like, comparing the taste to fat TUBERCULOSIS, PULMONARY 
TUBERCULOSIS, PULMONARY 
smoked mackerel. Creosote or guaiacol may be 
given with alcohol, in the form of sherry wine or 
rum, with or without the addition of gentian or 
glycerin; or in emulsion with cod-liver oil or olive 
oil; or in capsule with morrhuol or cod-liver oil. 
These drugs should not be given in capsule without 
an oily vehicle. They may be given with milk as a 
rectal injection or in oily solution of 10 percent or 
more by intratracheal injection or hypodermically. 
The dose is generally to be somewhat below the 
point of tolerance, the urine being carefully 
watched. Cases of sudden nephritis and other 
forms of poisoning are on record. Inunctions 
of guaiacol are valuable, especially in children. 
Gomenol is said to be a valuable substitute 
for creosote. 
Preparations of the creosote group are most use- 
ful in cases in which active inflammatory processes, 
catarrhal or tuberculous, are in process, and in cases 
with persistent high temperature, though they may 
be of service at all stages. Their action has not 
been satisfactorily explained. They probably have 
a good local influence during their elimination by 
the bronchial tract. 
Of the iodin group, iodoform is the most useful. 
It is best given in pill (sugar-coated) form. An 
excellent combination is iodoform and reduced 
iron, made into pills containing 1 grain of each, 
the dose being gradually increased to 3 or even 5 
pills at a time, after meals, thrice daily. It may 
sometimes be useful to combine other drugs than 
iron with the iodoform, in which case gelatin cap- 
sules may be used, Peruvian balsam being em- 
ployed as the vehicle. Iodoform may also be given 
by inunction, in cod-liver oil or lanolin, as advised 
by Flick, who employs europhen also in this way. 
It is most useful in the early stages of the disease or 
during periods of quiescence in the chronic forms. 
Creosote and iodoform may be given to the same 
patient in alternate doses or on alternate days, 
when the signs in various portions of the lungs so 
differ as to indicate an advanced or active pro- 
cess here, and a quite recent or sluggish process 
there. 
Cinnamic acid by intravenous injection is highly 
praised by Landerer, who reports a large propor- 
tion of successful cases. The dose is from 1/2 
milligram, gradually increased to a maximum of 
25 milligrams of sodium cinnamate, or cinnamylate 
dissolved in physiologic salt solution. The injec- 
tions are repeated about every 48 hours, and con- 
tinued for several months. The drug acts by 
increasing leukocytosis. During the past few 
years good results have seemed to follow the use of 
a solution of palladium chlorid (made with the aid 
of nitro-hydrochloric acid) of a strength of 15 
grains to the ounce, in doses of from 3 to 10 drops 
thrice daily in water, half an hour before meals. 
In several cases it seems to have been useful as a 
substitute for iodoform, rather than for creosote. 
If given for too long a time, or in too large doses, 
it causes rapid and irregular cardiac action. 
Extract of kalagua is the most recent drug that 
comes well recommended. It is given in doses of 
from 9 to 20 grains per diem. 
Mercuric succinimid in intramuscular injec- 
tions-extolled so highly by Barton Wright and 
others-has according to recent report proved 
not only worthless, but injurious. 
Of the drugs employed for the stimulation of 
general nutrition strychnin, arsenic (especially in 
the form of sodium cacodylate), iron, nuclein prep- 
arations, and the hypophosphites are the most 
useful. The best results usually follow from 
small, long-continued doses and alternation of 
remedies; though individual cases are benefitted 
by rapid increase to the point of tolerance. 
Digitalis is often useful as an adjunct to the 
roborant treatment, especially in cases of small 
heart and feeble circulation. In some instances 
nitroglycerin may be well combined with it. 
Digitalis has also special indication during acute 
processes, as long ago pointed out by Beddoes. 
In acute phthisis or in febrile exacerbations of 
chronic phthisis, it should be pushed to the point 
of tolerance. A good preparation, free from irri- 
tating impurities, is necessary. Pepsin prepara- 
tions given at the same time will help gastric 
toleration. When the leaves or tincture cannot 
be used, Merck's German digitalin, as recommended 
by Beates, may be tried. 
Oxygen is useless as a remedy, and may hasten 
death; but is among the best of palliatives in the 
latest stages. Combined with nitrous oxid, its 
inhalation relieves dyspnea and promotes the 
sense of well being. 
Nitrous oxid is among the best palliatives for 
the relief of cough, of insomnia, and of hectic fever. 
It is usually best to give it during the forenoon, at 
two periods separated by about 2 hours. Each 
inhalation may consist of from 3 to 8 gallons, air 
being allowed to enter through the nostrils and by 
the side of the mouth-piece. The patient breathes 
more freely and more deeply after the inhalation, 
and cough is quieted, but unconsciousness is not 
produced. 
Certain symptoms require special medication. 
Indigestion is to be treated on general principles, 
but carefully. 
Diarrhea is often troublesome, especially toward 
the end. Diet is to be regulated, milk being 
excluded, if necessary. Among useful drugs are 
beta-naphthol, benzonaphthol, beta-naphthol-bis- 
muth, bismuth salicylate, bismuth subnitrate or 
bismuth carbonate in large doses, bismuth sub- 
gallate, hematoxylin, silver nitrate, cupric sul- 
phate, zinc phenolsulphonate, plumbic acetate, 
and solution of potassium arsenite in small doses. 
Often morphin or opium is necessary. Before 
any drug is given the bowel should be thoroughly 
irrigated with saline solution, and a good cleans- 
ing from above with calomel or castor oil and 
aromatic syrup of rhubarb is often useful. 
Vomiting is often the result of cough, especially 
when there is much effort. In some cases it is 
nervous, and can be relieved by strychnin given at 
bedtime. Strontium bromid is among useful gas- 
tric sedatives. Otherwise general principles 
apply. 
Night-sweating can usually be checked by 
atropin in massive or divided doses of from 1/480 
to 1/40 grain at bedtime; it should be tried first in TUBERCULOSIS, PULMONARY 
TUMORS, CLASSIFICATION 
small doses, and increased, if necessary. Other 
useful drugs are picrotoxin, from 1/60 to 1/10 
grain hypodermically, if necessary; strychnin sul- 
phate or strychnin nitrate in the same dose; 
homatropin, of which the dose is said to be from 
1/2 grain to 2 grains; agaracin, from 1/8 to 1/2 
grain, 2 to 4 times daily; camphoric acid, from 10 
to'20 grains in capsule at bedtime; ergot; aromatic 
sulphuric acid. Dusting with zinc oxid, or spong- 
ing with a saturated solution of quinin in alcohol 
or with a saturated solution of alum in alcohol 
often helps to control this symptom. 
Hemorrhage varies from slight blood-spitting to 
considerable flow. It may be due to oozing from 
small vessels, to perforation of a large vessel, or to 
rupture of an aneurysm within a cavity, and the 
management varies accordingly. In many cases 
the bleeding ceases spontaneously, especially if the 
patient is kept at rest, and doubtless the popularity 
of many remedies is thus to be explained. If 
there is more than a mere trace of blood in the 
sputum the patient should be put to bed and given 
Cracked ice, which is to be allowed to melt slowly 
in the mouth from time to time. According to the 
severity of the case, some or all of the following 
measures are to be adopted: 
An ice-bag may be applied to the precordium, 
and kept on constantly, especially if there is an 
elevation of temperature. Tincture of aconite 
may be given in sufficient dosage to quiet the 
heart and to reduce and keep the pulse-rate to 60 
a minute. Crystallized calcium chlorid may be 
given in solution in doses of 15 grains every second 
hour, for about 4 days; it is then to be intermitted 
for 4 days or more, and used again, if need be. 
In the interval lead acetate, in doses not exceeding 
5 grains, thrice daily for 3 days, may be given, to 
be followed for 2 days by aromatic sulphuric acid 
in doses of 30 drops, well diluted, thrice daily or 
oftener. Hydrastinin hydrochlorid in doses of 
1/24 to 1/8 grain hourly or less often is sometimes 
useful. Among drugs to be recommended are 
also the turpentine group, of which erigeron is 
among the best. Fluidextract of matico is rec- 
ommended by Da Costa. Codein may be given 
by the mouth in doses of from 1/8 to 1/2 grain 
every second hour or less often; or morphin acetate 
may be given by the mouth in doses of 1/8 grain 
every hour or two; or morphin sulphate hypo- 
dermically in dose sufficient to prevent coughing 
absolutely in severe cases. 
Atropin sulphate, from 1/200 to 1/60 grain, 
may be given hypodermically at the beginning of 
the attack, and will often cut it short. 
- The patient must be forbidden to speak, except 
in a labial whisper. Cold liquid food should be 
given in small quantities at intervals of about 2 
hours. The bowels should be moved daily, with- 
out straining, by enema, glycerin suppository, or 
saline purge, as necessary. In desperate cases 
tannin has been injected into the lung, as also have 
gelatin solutions. 
Fever is best treated by rest (not necessarily in- 
doors) with cold applications, of which the pre- 
cordial ice-bag is the best. The coal-tar anti- 
pyretics may be cautiously used as palliatives, if 
necessary. Digitalis is often useful. Nitrous 
oxid is to be tried. 
Cough should not be interfered with unneces- 
sarily. It should be sufficient to expel the accu- 
mulations of mucopus in the trachea and larger 
bronchi. The expectorated matters are to be 
properly received, disinfected, and disposed of 
(see Cough). Cough may be checked, when 
excessive, by opium, hydrocyanic acid, chloro- 
form, or bromids. When unproductive, it needs 
to be made freer. The ammonium compounds 
are not often useful. As a rule, terebinthinates 
and balsamics, menthol, eucalyptol, terebene, 
terpin hydrate, and myrtol are the best agents for 
this purpose, internally or by inhalation. Steam 
inhalations are to be avoided, but dry inhalations 
of any volatile oil, of creosote, of well-diluted 
formaldehyd, or of ethyl iodid are serviceable. 
No apparatus except a containing phial is usually 
necessary, but various convenient forms of inhal- 
ers are manufactured. When cough is due to 
ulceration of the larynx, it is to be treated skil- 
fully, as described under Laryngitis (Chronic). 
Dysphagia, as a rule, is due to ulceration of the 
epiglottis, which requires local treatment. The 
food should be semisolid and bolted hastily. 
Cocain or other local anesthetic may be used with 
caution before meals. Rectal feeding or feeding 
through a nasal tube may have to be employed. 
Pain in the chest may often be relieved by rub- 
bing in a few drops of a solution containing one or 
more of the following agents with camphor (lique- 
faction taking place on mixing): Chloral, menthol, 
guaiacol, oil of gaultheria. Counterirritation 
with iodin or croton oil, or even the thermal point, 
is sometimes necessary. 
TUBERCULOSIS, SURGICAL.-See Bones (Dis- 
eases), Joints (Diseases), Lymphatic Glands 
(Diseases), etc. 
TUMENOL.-A dark-brown fluid, obtained by 
treating the unsaturated hydrocarbons of mineral 
oils with concentrated sulphuric acid. It is said 
to be a nontoxic and nonirritant protective and 
palliative to the skin. It is recommended in 
eczema, excoriations, erosions, superficial ulcera- 
tions and burns. The tincture is an efficient 
application in all forms of pruritus. Tumenol is 
of no service in erysipelas, and is not a parasiticide. 
TUMORS, CLASSIFICATION.*-In deference to 
the needs of the various registration authorities, a 
distinction between malignant and nonmalignant 
new growths is made in the general and local 
tables. The tumors are here classified, however, 
according to their structure and the type of nor- 
mal tissue they most closely resemble. To facili- 
tate returns under the general tables, the malig- 
nant growths are marked by two asterisks. In 
certain cases malignant and nonmalignant growths 
are unavoidably associated under one head, as, for 
instance, under sarcoma; the name is then marked 
with one asterisk. 
_ Cysts are placed in a separate class, and may be 
returned severally among the local affections of 
organs; or among new growths, if connected there- 
* Revised nomenclature of the Royal College of Physicians, 
1896. TUMORS, CLASSIFICATION 
TUMORS, CLASSIFICATION 
with; or as malformations, if congenital; or as 
parasites, if parasitic. 
Class I.-Tumors composed of one of the modi- 
fications of fully developed connective tissue. 
(The name of the typical normal tissue is printed 
first in each case; that of the tumor second.) 
Syr, a . .... ..... 
1. Adipose Tissue. Lipoma (fatty tumor). 
(a) Circumscribed. 
(b) Diffuse. Synonym,, fatty outgrowth. 
(c) Multiple. 
(d) Nevolipoma. 
(e) Fibrolipoma. ■ ■ 
2. Fibrous Tissue. Fibroma. . i.. . ' 
(a) Firm or hard fibroma (desmoid tumor). 
Fibrous epulis. 
Fibrous polypus of nose. 
Fibroma of nerves. Synonym, false neuroma. 
Keloid. 
(b) Soft or areolar fibroma. 
Molluscum fibrosum. 
3. Cartilage. Chondroma. 
(a) Ossifying. Synonym, spongy or cancellous ex- 
ostosis. 
(b) Nonossifying. 
*Enchondroma (when growing in bone)". 
Ecchondrosis (when growing from cartilage). 
(c) Myxochondroma (when undergoing mucous 
softening). 
4. Bone. Osteoma. 
(a) Developing from cartilage. 
Cancellous or spongy exostosis. 
(b) Developing from membrane. 
Compact or ivory exostosis. 
(c) Of teeth. 
(1) Growing from the cement. 
Dental exostosis. 
Hypertrophy of cement. 
(2) Growing from the dentin. 
Odontoma. 
5. Mucous Tissue. *Myxoma. 
Mucous polypus. 
6. Neuroglia. *Glioma. 
Class II.-Tumors more or less closely resem- 
bling in structure one of the more complex tissues 
or organs of the body. 
(The name of the typical tissue or organ is 
placed first; that of the tumor second.) 
1. Muscle. Myoma. 
(a) Unstriped (leiomyoma). 
Fibromyoma, uterine fibroid, fibroid tumor of 
prostate. 
(b) Striped (rhabdomyoma). 
♦Myosarcoma. 
2. Nerves. Neuroma (true neuroma). 
(a) Medullated. 
Plexiform neuroma (in part). Bulbous nerves. 
Synonym, amputation neuroma. 
(b) Nonmedullated. 
3. Blood-vessels. Hemangioma, angioma, or naevus. 
(a) Capillary. Synonyms, port-wine stain; mother's 
mark; telangiectasis. 
(b) Venous. Synonyms, erectile tumor; cavernous 
nsevus. / 
(c) With adipose tissue (nsevolipoma). 
4. Lymphatic Vessels. Lymphangioma, lymphatic naevus, 
congenital cystic hygroma of neck, macroglossia. 
5. Lymphatic Glands. Lymphadenoma. 
Hodgkin's disease. 
6. Papillae of Skin or Mucous Membrane. Papilloma. 
(a) Squamous papilloma (wart). 
(b) Columnar papilloma (villous growth). 
Of rectum. Of bladder. 
7. Secreting Glands. Adenoma. 
(a) Racemose adenoma (spaces lined with glandular 
or spheroid epithelium). 
(1) Resembling normal gland tissue (true ade- 
noma). 
(2) With excess of firm fibrous stroma (adeno- 
fibroma; adenoid tumor). 
(3) With stroma of imperfectly developed fibrous 
tissue (adenosarcoma). 
(4) With stroma containing mucous tissue (ade- 
nomyxoma). 
(5) With large cysts throughout the tumor (ade- 
nocystosarcoma; cystosarcoma). 
With simple cysts. .Withintracystic growths. 
(6) Tubular adenoma (spaces in tumor lined with 
columnar or cubic epithelium). 
(c) Adenoma of ductless glands (thyroid adenoma). 
(d) Ovarian adenoma. 
Class III.-Tumors composed of cells of an 
embryonic type sometimes tending to develop into 
one of the forms of connective tissue. 
*Sarcoma: 
1. Composed of small round cells. 
(a) With homogeneous intercellular substance (granu- 
lation sarcoma; encephaloid sarcoma). 
(6) With reticulate stroma (lymphosarcoma). 
(c) Ossifying sarcoma (osteoid sarcoma; osteoid 
cancer). 
(d) Chondrosarcoma (malignant chondroma). 
(e) Gliosarcoma. 
2. Composed of large round cells. 
With alveolar stroma (alveolar sarcoma). 
3. Composed of oval cells. 
With mucous intercellular substance (myxosarcoma). 
4. Composed of large spindle-cells (fibroplastic tumor). 
(a) Ossifying. 
(6) Chondrifying. 
5. Composed of small spindle-cells. 
(a) Developing into fibrous tissue (recurrent fibroid 
tumor). 
(6) Ossifying. 
6. Composed of round and spindle cells. 
7. Containing giant cells (myeloid sarcoma). 
8. Melanotic sarcoma (pigmented sarcoma). 
9. Plexiform sarcoma (cylindroma). 
10. Psammoma (brain-sand tumor). 
Class IV.-Tumors composed of epithelial cells 
arranged in the spaces of a stroma of more or less 
perfectly developed and vascular connective 
tissue. 
**Gar cinoma, or True Cancer. 
1. Glandular or spherical carcinoma. 
(a) With little stroma and abundant vessels (encepha- 
loid cancer). 
(6) With dense fibrous stroma (scirrhus, or hard 
cancer). 
Variety: Atrophic cicatrical scirrhus. 
(c) With colloid degeneration of cells (colloid cancer- 
reticular or alveolar cancer in part). 
(d) With a myxomatous stroma (carcinoma myxoma- 
todes). 
2. Squamous carcinoma. Synonyms, epithelioma; squa- 
mous epithelioma. 
Note.-Chimney-sweeper's cancer is to be re- 
turned under squamous carcinoma. 
3. Rodent cancer or rodent ulcer. 
4. Columnar carcinoma. Synonyms, Columnar epithe- 
lioma; adenoid cancer. 
(a) With colloid degeneration of cells (colloid cancer 
in part). 
(5) Arising in ducts (duct cancer). 
5. Thyroid carcinoma (resembling in structure the thyroid 
gland). 
Class V.-Cysts. 
1. Cysts Arising from the Distention of Preexisting Spaces. 
(a) Spaces lined with secreting epithelium (retention 
cysts). 
(1) Acinous or glandular cyst of breast, pan- 
creas, and other glands. 
(2) Duct cyst of the breast, pancreas, testicle, 
and other glands. 
(3) Galactocele. 
(4) Spermatocele. 
(5) Mucous cyst Ranula. Labial cyst. 
(6) Sebaceous or atheromatous cyst (wen). 
(7) Ovarian cyst from Graafian follicles. TUMORS, CLASSIFICATION 
TUMORS, CLASSIFICATION 
(6) Spaces lined with flattened endothelium (distention 
or exudation cysts; lymphatic cysts). 
(1) Bursal cysts. 
(2) Ganglion. 
(3) Serous cysts. 
2. Cysts in which the Fluid is Contained in a Space of 
New Formation. 
(a) Blood cyst. Apoplectic cyst in brain. 
(b) Degeneration cyst. In brain. In tumors. 
3. Cysts of Congenital Origin. 
(a) Inclusion cyst. Dermoid cyst. 
(b) Cysts arising in the remains of fetal structures. 
(1) Unobliterated branchial clefts. 
Deep cysts of neck. 
(2) Unobliterated canal of His. 
Sublingual cysts in part. 
Subhyoid cysts in part. 
Cysts in front of larynx. 
(3) Remains of Wolfflan body. 
Encysted hydrocele in male (in part). 
Cysts of the broad ligament in female (in 
part). 
(4) Partially unobliterated processus vaginalis 
testis. 
Encysted hydrocele of cord. 
(5) Partially unobliterated canal of Nuck. 
Hydrocele of canal of Nuck. 
(6) Cysts of postanal gut. 
4. Parasitic Cysts. 
Another classification (by Coplin) gives a clear 
and schematic arrangement: 
(Those printed in italics are malignant.) 
TUMORS. 
Skin warts. 
Villous warts. 
Intracystic warts. 
Papilloma 
Acinous. 
Tubular. 
Adult (Typical Be- 
nign) 
Adenoma 
Ganglionic neuroma. 
Myelinic neuroma. 
Amyelinic neuroma. 
Epithelial (Epiblast 
and Hypoblast) 
Neuroma 
Glioma 
Squamous. 
Tubulated. 
Cylindric. 
Embryonic (Atypical, 
Malignant) 
Carcinoma, or 
Cancer 
Epithelioma 
Glandular 
Scirrhus. 
Encephaloid. 
(Colloid 
Simple. 
Fibrous. 
Mucoid, Mel- 
anotic.') 
Lipoma 
Chondroma 
Osteoma 
Eburnated. 
Compact. 
Spongy. 
Simple 
Fibroma 
f Hard. 
I Soft. 
Adult (Typical or 
Benign) 
Fibroma Molluscum. 
Keloid. 
Neoplasms 
Myoma 
Leiomyoma (Unstriped). 
Rhabdomyoma (Striped). 
Angioma 
Hemangio- 
ma (Blood- 
vessels) 
Simple. 
Cavernous. 
Plexiform. 
Connective tissue 
(Mesoblast) 
Lymphoma (?) 
Myxoma 
Lymphangioma 
(Lymph-vessels). 
Round-cell 
Large. 
Small. 
TUMORS. 
Embryonic (Atypical, 
Malignant) 
Sarcoma 
Spindle-cell 
Large. 
Small. 
Myeloid. 
Mixed-cell. 
Alveolar 
(Melanotic, 
Cystic, etc.). 
Mixed .Teratoma. 
(Both Epithelial and Connective-tissue). 
Cysts 
(1) Retention (occluded excretory ducts). 
(2) Exudation (accumulations in closed cavities). 
(3) Cystomata (new formation). 
(4) Extravasation (those forming from extravasations). 
(5) Dermoid (congenital and due to inversion of the cutis and to imperfectly closed fetal clefts). 
(6) Parasitic (due to animal parasites). 
(7) Cysts resulting from necrotic and degenerative charges. TUMORS 
TUMORS 
TUMORS, TABLE OF. 
Name. 
Histologic Constituents. 
Physical Manifestations. 
Appearance of 
Section. 
Size. 
Adenoma. 
1. Acinous. 
Acini lined with spheroidal epi- 
thelium, with varying amount 
of connective tissue, as in a 
normal gland. 
1. A drums. 
Firm, rather hard consistence; 
inelastic; tabulated; light-gray 
or slightly yellow color; mov- 
able; encapsulated; generally 
single; rounded; when on mu- 
cous surfaces, flat and irregu- 
lar. 
Gray or yellowish- 
white; of variable 
density; often inter- 
mingled with cysts. 
1. Acinous. 
Cherry or 
walnut;in 
the breast; 
large. 
2. Tubular. 
Tubules lined with cylindrical 
epithelium. 
2. Tubular. 
Soft; frequently pedunculated; 
grayish-white or reddish color; 
translucent. 
2. Tubular. 
Small. 
Angioma. 
1. Telangiectatic. 
1. Telangiectatic. 
Dilated blood-vessels. 
1. Telangiectatic. 
Surface often covered with small, 
granular elevations, resembling 
a strawberry; often well cir- 
cumscribed. 
Red color; affecting in 
part the corium; in 
part the subcutane- 
ous adipose tissue. 
Patch on the 
skin the size 
of a millet- 
seed to sev- 
eral inches 
in extent. 
2. Cavernous. 
2. Cavernous. 
Spaces lined with endothelial cells 
and filled with blood, like cor- 
pora cavernosa of penis. 
2. Cavernous. 
Soft, doughy; nonpulsating; 
leaden or blue color. 
2. Cavernous 
Usually 
small. 
Carcinoma. 
1. Scirrhous 
(hard, s p h e - 
roidal-celled). 
1. Scirrhous. 
Hard, irregular, tuberous; ad- 
herent to surrounding tissues; 
ulcerated. Nonencapsulated. 
Ulcer.-Irregular in outline and 
depth; margins hard, nodular, 
everted. 
1. Scirrhous. 
Firm; white; often 
traversed by fibrous 
septa; creaking 
under the knife; 
cupped. Scrap i n g 
exposes a milky 
fluid, the so-called 
" ca-ncer-juice." 
1. Scirrhous. 
Moderate. 
2. Encephaloi d 
(soft, s p h e - 
roidal-celled). 
Large epithelial cells containing 
one or more nuclei, without 
visible intercellular matrix, 
grouped into acini (cancer-nests). 
Vessels have walls of normal 
thickness and constitution, and 
ramify in the stroma, and not 
among the cells themselves. 
2. Encephaloid. 
Soft, globular, or bossellated; 
elastic, compressible; fluctuat- 
ing; nonencapsulated. 
2. Encephaloid. 
Resembles brain- tis- 
sue. 
2. Encepha- 
loid. 
Considerable. 
3. Colloid (prob- 
ably a degen- 
eration of one 
of the preced- 
ing varieties). 
Three varieties are described 
histologically: (a) squamous, 
made up of squamous or flat 
epithelium; (b) cylindrical, con- 
taining columnar cells; (c) 
glandular, composed largely of 
polyhedral cells, like those of 
secreting glands. 
3. Colloid (usually mucoid). 
Soft; jelly-like; contains mucoid 
material; semi translucent; glis- 
tening; at places diffluent. 
3. Colloid. 
Amorphous; jelly- 
like. 
3. Colloid. 
Large or 
small. 
Chloroma. 
A form of round-celled sarcoma 
(which see). 
Small nodules. 
Greenish or dirty color 
on section. 
Small. TUMORS 
TUMORS 
TUMORS, TABLE OF. 
Seats of Predilection. 
Degenera- 
tion to 
which Sub- 
ject. 
Age. 
Growth. 
Nature. 
Fre- 
quency. 
Illustrations. 
{From Ziegler and Woodhead.) 
1. Acinous. 
Mamma, lip, ovary, testis, 
prostate, thyroid, parotid, 
lacrimal gland, sudorifer- 
ous and sebaceous glands. 
2. Tubular. 
Rectum and other por- 
tions of intestines; uterus. 
Mucous. 
Fatty. 
Colloid. 
Cystic. 
Young 
adults. 
Slow. 
. < 
Benign; the 
flat ade- 
noma may 
become 
malignant. 
Rare. 
M 'A 
1. Telangiectatic. 
Skin, mucous membrane, 
brain, bones, and mamma. 
2. Cavernous. 
Liver, kidney, spleen, 
uterus, bones, muscle. 
{Illustrated). 
Uusally 
c o n - 
genital. 
Usually 
slow. 
Benign. 
Common. 
ml 
1. Scirrhous. 
Mamma; alimentary tract 
(especially the pyloric end 
of stomach); glands of 
the skin (rare); rectum; 
uterus. 
2. Encephaloid 
Testicle; ovary; mucous 
membranes. 
3. Colloid. 
Stomach; intestine; ovary; 
mamma; thyroid. 
{The illustration is of Myx- 
omatous Carcinoma.) 
Horny. 
Fatty. 
Cystic. 
Colloid. 
Mucoid. 
Hyaline. 
Caseous. 
Pigmentary. 
Ulcerative. 
Calcareous 
(rare). 
Adults 
past 40 
years 
of age. 
Slow, but 
may be 
rapid. 
Malignant. 
Metastas i s 
takes place 
by means 
of the lym- 
p h a t i c s, 
but carcin- 
oma of 
the stom- 
ach and 
intest i n e s 
invades 
the liver 
by the por- 
tal blood- 
paths. 
Common. 
Ml®®1 
Periosteum of skull. 
Fatty. 
Young 
adults. 
Rapid. 
Malignant. 
Rare. 
Same as Round-celled Sarcoma. TUMORS 
TUMORS 
TUMORS, TABLE OF. 
Name. 
Histologic Constituents. 
Physical Manifestations. 
Appearance of 
Section. 
Size. 
Cholesteatoma. 
Concentric layers formed of flat 
cells of an epithelial character, 
arranged in whorls enclosing 
cholesterin plates. Belongs 
probably to the Teratomata 
from the occurrence in it of se- 
baceous glands, hair-follicles, 
etc. 
Solitary or multiple nodules or 
nodes. 
Shining, glistening. 
Small. 
Chondroma. 
(Enchondroma.) 
Hyaline or fibro-cartilage, with 
few blood-vessels. The cells are 
arranged irregularly and have 
irregular shapes, many being 
stellate or spindle-shaped. 
Hard; elastic; nodular or lobu- 
lated, sometimes smooth; round; 
encapsulated; usually single, 
but may be multiple and sym- 
metric. 
Homogeneous or 
coarsely granular; 
translucent; bluish- 
gray or pinkish- 
white; often marked 
by connective-tissue 
septa. 
Small if 
multiple; 
large if 
single. 
Endothelioma. 
Multiplication of endothelial cells 
lining lymph-passages. A varie- 
ty of sarcoma. Large, round cells 
containing one or two nuclei. 
Resembles epithelial new- 
growths. 
Circumscribed or extensive flat 
growths, spreading over the ser- 
ous membranes; white in color. 
Small nod- 
ules or ex- 
tensive in- 
filtration. 
Epithelioma. 
1. Squamous. 
Composed of pegs or columns of 
cuboidal epithelial cells which 
first infiltrate the subjacent con- 
nective tissue, then every under- 
lying structure, including bone, 
in their track. These ingrowths 
contain the cell-nests, epidermal 
pearls, or pearly bodies. 
Dense; inelastic; nonencapsu- 
lated; ulcerated; edges of ulcer 
indurated. 
1. Squamous. 
White; dense; homo- 
geneous ; poor in 
juice; when scraped 
a gruel-like material 
is obtained, which 
consists of plugs of 
cells and individual 
cells. 
2. Cylindric- 
celled or colum- 
nar-celled. 
Originates either from the cylin- 
dric surface-epithelium of a mu- 
cous membrane, or from that of 
glands lined by columnar epi- 
thelium. Contains no "cell- 
nests." Consists of alveoli con- 
taining cylindric cells at the 
periphery, and irregular cells in 
the center. Presents the charac- 
ter of adeno-carcinoma. 
Soft, infiltrating masses or nodes, 
or papillomatous growths. 
2. Cylindrical. 
Soft, juicy; gelatinous 
if mucoid or colloid. TUMORS 
TUMORS 
TUMORS, TABLE OF. 
Seats of Predilection. 
Degenera- 
tion to 
which Sub- 
ject. 
Age. 
Growth. 
Nature. 
Fre- 
quency. 
Illustrations. 
(From Ziegler and Woodhead.) 
Brain and meninges. 
Nonmalig- 
nant. 
Rare. 
The bones, especially on or 
in the phalanges; scapula, 
ilium, upper jaw; subcu- 
taneous tissue; salivary 
glands (parotid); testicle; 
bronchial cartilages. 
Fatty. 
Mucoid. 
Calcareous. 
Usually 
in the 
young. 
Slow or 
rapid. 
Benign; may 
assume 
malignant 
characteris- 
tics. 
Common. 
Cystic. 
'w: 
Pleura and peritoneum; 
membranes of brain. 
Young 
adults 
Rapid. 
Malignant. 
Very rare. 
1 
■1 
• 
1. Squamous. 
Nose, lower lip, penis, scro- 
tum, vulva, anus, tongue, 
gums, palate, tonsils, lar- 
ynx, pharynx, esophagus, 
bladder, os uteri, hands 
and feet (rare). 
Horny. 
Ulceration. 
After 
40. 
Slow or 
rapid, ac- 
cording 
to situa- 
tion. 
Malignant. 
Late metas- 
tasis. 
Common. 
2 Cylindrical. 
Stomach; intestinal tract; 
uterus; gall-bladder; bil- 
iary passages; respiratory 
tract. 
Mucoid. 
Colloid. 
In uter- 
us be- 
fore 40. 
Varies in 
its rapid- 
ity. 
Malignant. 
Late metas- 
tasis. 
Quite com- 
mon, es- 
pec ially 
in diges- 
tive tract. TUMORS 
TUMORS 
TUMORS, TABLE OF. 
Name. 
Histologic Constituents 
Physical Manifestations. 
Appearance of 
Section. 
Size. 
Fibroma. 
1. Hard. 
White, fibrous tissue, consisting 
of fibers and few connective- 
tissue corpuscles; blood-vessels 
few. 
2. Soft. 
Few fibers, many cells 
1. Hard. 
Ovoidal or spherical; lobulated; 
nodular or bossellated; pedun- 
culated or sessile; firm, elastic; 
encapsulated; glistening white, 
yellowish, or slightly red color; 
unattached to overlying tissues; 
single or multiple. 
2. Soft. 
Soft, compressible; sessile or pen- 
dulous; single or multiple; en- 
capsulated. 
1. Hard. 
Smooth, glistening, 
firm; grayish-white 
color. 
2. Soft. 
Moist, not so glisten- 
ing; more reddish. 
From a grain 
of shot to 
fetal head or 
, much larg- 
er. 
Glioma 
Round cells, with large nuclei, 
embedded in a scanty, granular, 
intercellular substance. After 
the type of the neuroglia of the 
brain. 
Soft, gelatinous, glue-like tumor; 
not distinctly outlined; some- 
what translucent. Usually 
single. 
Like brain-tissue, but 
usually a little harder 
and more reddish in 
color. 
Small, rarely 
larger than 
a fist. 
Lipoma 
Adipose tissue (fat-vesicles larger 
than normal) bound together by 
delicate connective tissue. 
Circumscribed; lobulated, soft, 
doughy, pseudo-fluctuating, in- 
elastic; attached to the skin- 
hence dimpled; ovoidal, spheri- 
cal, or flattened; occasionally 
pedunculated; usually sur- 
rounded by a thin capsule; usu- 
ally single; when multiple, usu- 
ally hereditary. 
Like adipose tissue... 
From size of 
hickory-nut 
to very 
large size. 
Lymphangioma.. 
Aggregation of dilated lymphatic 
vessels and lymph-spaces sup- 
ported by connective tissue. 
Soft, doughy, transparent sacs or 
vesicles, filled with lymph; often 
feels like a series of tangled 
cords. 
From a 
cherry to 
fetal head. 
Lympho-sarco- 
ma. 
Hyperplasia of the lymphoid cells 
of the lymphatic glands. 
Glands for a time preserve their 
shape, but soon extends to 
neighboring tissues. 
Large. 
Myoma. 
Smooth, non-striated, muscular 
Rounded or pyriform, well-cir- 
A striated appearance 
Often quite 
1. Leiomyoma. 
fibers, such as occur in the uter- 
us, with varying quantities of fi- 
brous tissue; few blood-vessels. 
The fibers are composed of spin- 
dle-shaped cells containing large, 
rod-shaped nuclei. 
cumscribed; hard; firm; smooth 
or nodular; white or flesh-color- 
ed; encapsulated or non-encap- 
sulated; often multiple. 
as in the fibroma. 
large. 
2. Rhabdomyo- 
ma. 
Striated muscular fibers, often 
undeveloped, being spindle- 
shaped, and associated with 
sarcomatous tissue. 
Large roundish masses or small 
nodules. 
Very large if 
in kidney; 
small in 
heart. TUMORS 
TUMORS 
TUMORS, TABLE OF. 
Seat of Predilection. 
Degenera- 
tion to 
which Sub- 
ject. 
Age. 
Growth. 
Nature. 
Fre- 
quency. 
Illustrations. 
(From Ziegler and Woodhead.) 
Uterus; periosteum; ovary; 
labium majus; mamma; 
testicle; tendons; aponeu- 
rosis; neurilemma of 
nerves; around articula- 
tions; subcutaneous tis- 
sue; rectum. 
Ulceration. 
Calcification. 
Myxomatous. 
Fatty. 
Telangiecta- 
tic. 
Chiefly 
in ad- 
u 1 t s 
from 
35 to 
55 yrs. 
of age. 
Slow 
Benign 
Very com- 
mon. 
We : 
Ok r 
A- ; 
Brain; retina; spinal cord; 
optic and auditory nerves; 
suprarenal capsules. 
Mucoid. 
Fatty. 
Calcareous. 
Telangiecta- 
tic. 
Partic- 
ular 1 y 
in chil- 
dren. 
Slow 
Benign, ex- 
cept in the 
eye, where 
it is usual- 
ly combin- 
ed with 
sarcoma. 
Rare...... 
i 
Back of neck; shoulders; 
back; nates; inside of arm 
and thigh; submucous and 
subserous connective-tis- 
sue. 
Calcareous. 
Myxomatous. 
Cystic. 
Inflamma- 
tion. 
Ulceration 
(rare). 
Chiefly 
during 
adult 
life. 
Slow 
Benign 
Very com- 
mon. 
Posterior and inner sur- 
faces of thigh; genitals; 
anterior abdominal wall, 
neck, nates, axilte, groin, 
penis, tongue, cheeks, lips, 
liver, kidney. 
Usually 
con- 
geni- 
tal 
Slow 
Benign 
Rare. 
Neck, groin, axilla, medi- 
astinum, etc. 
Young 
adults. 
Rapid.... 
Very malig- 
nant. 
Rare. 
Uterus, esophagus, intes- 
tine, prostate, stomach. 
Kidney, ovary, testicle; 
tongue, heart. 
Calcareous. 
Fatty. 
Myxomatous. 
Cavernous. 
Mature 
or ad- 
vanced 
life. 
Con- 
geni- 
tal. 
Slow 
Rapid.... 
Benign 
Malignant in 
the seg- 
mental or- 
gans and 
kidney, 
ovary, tes- 
ticle when 
comb i n e d 
with sar- 
coma. 
Very com- 
mon. 
Rare. TUMORS 
TUMORS 
TUMORS, TABLE OF. 
Name. 
Histologic Constituents. 
Physical Manifestations. 
Appearance of 
Section. 
Size. 
Myxoma 
Delicate network of stellate cells 
Round or lobular; soft, gelatin- 
Pinkish or yellowish- 
Usually 
enclosing a mucoid intercellular 
substance. Type-Wharton's 
jelly; vitreous humor. 
ous; semi-translucent; encapsu- 
lated; elastic; may be fluctuat- 
ing. 
gray, exuding a 
glairy fluid, or a 
trembling, gelatin- 
ous mass. 
small 
Neuroma 
Medullated or non-medullated 
nerve-fibers. Very rarely may 
contain ganglionic cells; usually 
combined with fibrous tissues. 
Spheric, ovoid, oblong, or bul- 
bous; sometimes plexif orm; 
firm; painful on pressure; few 
or many (even hundreds). 
Often resembles fibro- 
ma. 
Small. 
Osteoma 
Osseous tissue (cancellous or com- 
pact bone). 
Hard; often lobulated; some- 
times spheric; may be spinous or 
spiculated; pedunculated or 
sessile; usually single; may be 
multiple and symmetric. 
Like bone-tissue 
Variable; 
grain of.cof- 
fee to cocoa- 
nut. 
Papilloma 
Hypertrophied papillae of the skin; 
varying amount of connective 
tissue surrounding two or more 
central blood-vessels, and cov- 
ered by several layers of epithe- 
lial cells. 
Circumscribed; hard (on the 
skin); soft (on mucous mem- 
brane); surface smooth, brush- 
like, or cauliflower-like; single 
or multiple. 
U s u a J 1 y 
small; may 
be large. 
Psammoma 
A form of sarcoma {nest-celled}. 
Connective tissue composed of 
flat, elongated cells of great size 
and in which are embedded 
gritty concretions that are com- 
posed of calcium carbonate. 
Hard, circumscribed; light color. 
White; gritty on sec- 
tion. 
Small. 
Sarcoma. 
1. Round-celled.. 
Embryonic or immature con- 
Soft; vascular; whitish; some- 
Resembles brain-mat- 
Often very 
nective tissue. Blood-vessels 
without walls, or thin-walled, 
ramifying among the cells. 
Small or large round cells, em- 
bedded in a small amount of 
granular or homogeneous inter- 
cellular substance. 
what translucent; on pressure 
after some hours exudes a milky 
fluid; round or ovoid, or oblong. 
ter; of a yellow, gray, 
or brick-dust hue. 
large. 
2. Spindle-celled. 
Cells varying much in size, spin- 
dle-shaped, with long, fine 
tapering extremities, separated 
by very little intercellular sub- 
stance. Often have a fibrous 
appearance (RecurrentFibroid). 
Firm; reddish ^does not exude 
milky fluid Shape as foregoing. 
Fibrous or flesh-like 
aspect; pinkish color. 
May be large. TUMORS 
TUMORS 
TUMORS, TABLE OF. 
Seat of Predilection. 
Degenera- 
tion to 
which Sub- 
ject. 
Age. 
Growth. 
Nature. 
Fre- 
quency. 
Illustrations. 
{From Ziegler and Woodhead.) 
Nasal cavities; mamma; in- 
termuscular spaces; sub- 
mucous and sub-serous 
tissues; back; thighs; lip; 
cheek; labia; clitoris; pre- 
puce; scrotum; axillae; 
parotid; ear; more rarely 
periosteum, bone, heart, 
and nerve-sheaths. 
Fatty. 
Ulceration. 
Telangiecta- 
tic. 
Any age; 
may 
be con- 
geni- 
tal. 
Slow 
Benign 
Common. 
Cut ends of nerves; as in 
stumps of amputation, on 
skin. 
Slow 
Benign. 
Somewhat 
rare. 
Cranial bones, maxilla, 
orbit; ends of phalanges; 
juxta-epiphyseal portions 
of long bones (tibia, femur, 
humerus, etc.); dura 
mater; muscle; aponeuro- 
sis; lungs. 
Con- 
genital 
or early 
life. 
Slow. 
Benign. 
Not com- 
mon. 
Skin of hands and genitalia; 
larynx; bladder; rectum; 
nose. 
At all 
ages. 
Slow or 
rapid. 
Benign. 
Common. 
Membranes of brain, cho- 
roid plexus; pineal gland; 
spinal cord; nerves. 
Calcareous. 
Early 
life. 
Rapid. 
Malignant. 
Rare. 
Periosteum; bone; lym- 
phatic glands; subcutan- 
eous tissue; testicle; eye; 
ovary; lungs; kidneys; in- 
termuscular septa. 
Mucoid. 
Fatty. 
Ulceration. 
Calcareous. 
Ossification. 
Telangiec- 
tatic. 
Cystic. 
Youth, 
or be- 
f o r e 
35th 
year. 
Very 
rapid. 
Malignant. 
Early metas- 
tasis. Dis- 
semination 
by the 
blood-ves- 
s e 1 s and 
not by the 
lymphatics. 
Common. 
< y5- • * 
' • "A » 
Subcutaneous tissue; fas- 
ciae and intermuscular 
septa; periosteum; in- 
terior of bones; eye; an- 
trum; breast; testicle. 
As foregoing. 
As fore- 
going. 
Rapid. 
Malignant 
by recur- 
rence. 
Common. TUMORS 
TUMORS, ETIOLOGY 
TUMORS, TABLE OF. 
Name. 
Histologic Constituents. 
Physical Manifestations. 
Appearance of 
Section. 
Size. 
Sarcoma {Contd.) 
• 
3. Giant-celled 
{Myeloid.) 
Masses of protoplasm containing 
two or more nuclei-up to 20 or 
50-with a varying amount of 
round and spindle cells. 
Jelly-like consistence or firm, like 
muscle. Shape as foregoing. 
Smooth, shining, suc- 
culent; no appear- 
ance of fibrillation; 
greenish or livid red 
or maroon color, 
varied by pink or 
darker red spots, due 
to extravasation of 
blood. 
Large. 
4. Alveolar. 
Alveolar space filled with sarcoma 
cells; the trabeculae composed 
of spindle-cells. 
Very vascular; soft 
Small or 
large. 
5. Melanotic. 
Sarcomata of various kinds in 
which brownish or black pig- 
ment becomes deposited as 
amorphous granules in the cells 
as well as the connective tis- 
sue and blood-vessel walls of 
the tumor. 
Rounded, nodular, dark colored 
tumors of varying size and con- 
sistency, usually hard. 
Brownish or black. 
May be 
large. 
Dermoid Cyst.... 
Cyst wall contains hair-follicles 
and sebaceous glands. Con- 
tents.-Disintegrating epithelial 
cells, hair, sebaceous matter, 
teeth, etc. 
Globular; tense; smooth; freely 
movable. 
May be 
large. 
TUMORS, ETIOLOGY.-It is not improbable 
that different tumors arise as a result of the action 
of various causes. As, however, we know very 
little concerning the exact etiology of any particu- 
lar tumor, certain general considerations are per- 
missible. The older theories, attributing the 
occurrence of tumors to alterations in the humors 
of the body, particularly of the blood, and similar 
hypotheses, may be at once discarded. The fol- 
lowing hypotheses are deserving of consideration: 
1. The Durante-Cohnheim Inclusion Theory.- 
This theory is based upon the supposition that, 
during embryonic development and the specializa- 
tion of the cells entering into the formation of 
organs and adult tissues, more embryonic elements 
are produced than are necessary, and that these 
cellular elements become quiescent in the tissues, 
where they may remain, constituting embryonic 
"rests" or "remnants," from which, later, tumor 
formation takes place. Such embryonic rests or 
remnants would be exceedingly likely to occur 
where developmental processes are complex, as, 
for example, where different forms of epithelium 
join. Such points of tumor election undoubtedly 
occur, as is shown by the development of cancer 
at the various orifices of the body and at points of 
epithelial transition, such as the lip, cervix uteri, 
etc. This theory also explains to advantage the 
occurrence of chondroid tumors in or from bone, 
and of melanotic sarcomata from quiescent 
pigmented cells in moles, and affords a most 
acceptable explanation for the development of 
dermoid cysts. The theory, however, is wanting 
in several ways. In the first place, admitting the 
occurrence of these remnants, it would appear 
that a further etiologic factor is necessary in order 
to stimulate them to renewed activity. Another 
objection is afforded by the fact that many 
localities in which complex developmental processes 
occur, such as the heart and the nervous system, 
are singularly free from tumors, and that when they 
do occur in such tissue, they are not commonly 
situated at points at which the complexity of 
development is most marked. Epithelial rests 
are sometimes demonstrable, and yet no tumor 
formation occurs. The occurrence of tumors as TUMORS 
TUMORS, ETIOLOGY 
TUMORS 
TUMORS, ETIOLOG 
TUMORS, TABLE OF. 
Seat of Predilection. 
Degenera- 
tion to 
which Sub- 
ject. 
Age. 
Growth. 
Nature. 
Fre- 
quency. 
Illustrations. 
{From Ziegler and Woodhead.) 
Lower and upper jaw; 
lower end of femur; head 
of tibia. 
Usually 
in 
adults 
over 40. 
Slow. 
Compara- 
tively be- 
nign. Met- 
a s t a s i s 
rare. 
Rarer than 
the pre- 
c edin g 
forms. 
i / 
IM 
Skin; eye; bone; lymphatic 
glands, pia mater of brain. 
Often springs from warts. 
Where pigment occurs nor- 
mally; the eye and the 
skin, the pia; secondarily, 
especially in the liver. 
As other sar- 
comata. 
In the 
young. 
As 
other 
sarco- 
mata. 
Rapid. 
Usually 
rapid. 
Malignant. 
Very malig- 
nant. 
Rare. 
Common. 
Outer angle of orbit; over 
root of nose; ovary; testi- 
cle. 
Con- 
genital. 
Slow 
Benign. 
Common. 
TUMORS, TABLE OF. 
the result of trauma (to be considered later) is 
inconsistent with this theory. 
2. Injury and inflammation appear to be, in a 
certain percentage of tumors, important etiologic 
factors. Persistent or long-continued irritation 
seems to favor the development of tumors belonging 
to the' epithelial group. As examples of such 
tumors the following may be mentioned: Car- 
cinoma of the scrotum in chimney-sweeps; 
epithelioma of the arm in workers with paraffin 
and tar; smokers' cancer of the lip or tongue and 
cancer of the tongue apparently due to injury by 
a carious tooth; and epithelioma originating in 
the margins of chronic ulcerative processes. 
Among the nonmalignant epithelial tumors the 
development of which appears to be favored 
by injury or irritation may be cited the papillo- 
matous masses due to the accumulations of ir- 
ritating discharges, particularly around the anus 
and external genital organs, when the parts are 
not kept properly cleansed. Sarcoma following 
fracture or injury of bone, and fibroneuromata 
of the severed ends of nerves after amputation, 
may be mentioned as connective-tissue tumors 
offering strong support to this theory The 
occurrence of tumors at points particularly liable 
to injury is another argument in its favor. 
Numerous objections have been made to the 
acceptance of this theory. In about 85 percent 
of all tumors no history of injury can be obtained. 
On the other hand, the frequency with which in- 
juries are received is out of all proportion to the 
total number of tumors occurring. Parts particu- 
larly subject to injury, such as the hands and feet 
are not commonly affected, and the nipple, which 
is frequently injured, is rarely the seat of a 
tumor. 
3. Parasitic Influence.-The germ theory has 
been invoked to explain the formation of tumors, 
particularly the malignant neoplasms, in which 
metastases are conspicuous. By some the essen- 
tial parasitic body is believed to be an animal 
parasite belonging to the protozoa and resembling, 
if not identical with the coccidia. Others believe 
that the infecting body is a vegetable organism 
belonging to the blastomycetes. In further sup- TUMORS, ETIOLOGY 
TURPENTINE 
port of the parasitic origin of tumors the demon- 
strable autoinoculability of cancer is adduced. 
Thus, it has been shown that cancer of one labium 
may attack the point of contact upon the opposite 
labium; cancer of the cervix may attack the con- 
tiguous vaginal vault; and cancer reaching the 
peritoneal surface may show a similar inoculability. 
4. Parasitism of Cells.-It is not impossible that 
normal cellular elements may take on a certain 
parasite-like property that, in the presence of 
reduced resistance afforded by other elements, 
permits of their extension beyond normal limits. 
Thus, in cancer cellular elements that we believe 
to be of epithelial origin are found abundantly 
infiltrating connnective tissues. Normally, epi- 
thelium does not so extend, nor, in most instances, 
even when introduced experimentally, does it 
acquire any such property. Should further ex- 
periment show that conditions may arise under 
which epithelium can acquire or manifest the 
faculty of intraconnective-tissue growth, without 
the intervention of any other factor, we may 
assume that the manifestation of this parasite-like 
character leads to the development of cancer. 
5. Adami presents a most fascinating argument 
in favor of his view that whatever may be the 
origin of tumors, the most important element 
in their production is the fact that the cells form- 
ing the neoplasm give up the habit of function and 
acquire the habit of growth. Reproduction is of 
course an essential function in all cells, but in 
addition to proliferative power every cell is en- 
dowed with the inherent capacity to perform 
some specific duty, in the consummation of which 
it utilizes more or less of the energy that it is able 
to transform from the nutrition supplied. If the 
cell ceases to perform this specific function, 
whatever that duty may be, the energy previously 
converted in that direction is now transferred to 
the reproductive capacity of the cells, thereby 
leading to proliferaton in excess of the normal. 
The originator of this suggestive hypothesis fully 
recognizes the necessity for some reason account- 
ing for the cell's acquisition of the habit of growth 
at the expense of the habit of function. The fact 
that malignant neoplasms of epithelial origin, 
and particularly those arising from the mammary 
gland and uterus, appear at a time when function 
is on the decline, is fully in support of Adami's 
view. He further maintains that irritation, para- 
sitic or otherwise, may so modify the cell that pro- 
liferation becomes excessive and secretion or other 
specific function proportionately diminishes. 
6. Predisposing Causes.-The foregoing brief 
consideration of the most plausible reasons ad- 
vanced to explain neoplastic growths indicates 
our ignorance of the essential etiologic factor in 
tumor formation. There are, however, certain 
predisposing elements worthy of consideration. 
Some of the conditions previously considered 
may be active only in this way. Trauma and 
inflammation may predispose to tumor formation, 
just as they predispose to infection, and long- 
continued irritation or prolonged ulceration may 
act only as predisposing elements. With regard 
to age, it may be said, in a general way, that 
physiologic activity favors the development of 
sarcoma, while senescence, or physiologic decline, 
predisposes to the occurrence of cancer (Da Costa). 
The influence of inheritance cannot be entirely 
ignored, although it is probably slight (Coplin). 
TUMORS, TREATMENT.-See special articles, 
Bones, Breast, Carcinoma, Epithelioma, 
Sarcoma, Stomach, Uterus, etc. 
TURPENTINE (Terebinthina).-A turpentine 
means a vegetable exudation, liquid or concrete, 
consisting of resin combined with a peculiar essen- 
tial oil named oil of turpentine, C10H16, and gener- 
ally procured from various species of the natural 
order Pinaceae. Of the many turpentines two only 
are official, viz.- 
Terebinthina, Turpentine-a concrete oleoresin 
from Pinus palustris, the yellow pine, and other 
species of Pinus. It occurs in tough, yellowish 
masses, brittle when cold, crummy-crystalline 
interiorly, of terebinthinate odor and taste. Dose, 
5 to 30 grains as a stimulant, antispasmodic or 
diuretic; 2 to 4 drams as an anthelmintic. 
Terebinthina Canadensis, Canada turpentine 
(balsam of fir)-a liquid oleoresin obtained from 
Abies balsamea, the silver fir or balm of Gilead. 
A yellowish, transparent, viscid liquid, of agree- 
able, terebinthinate odor and a bitterish and 
slightly acrid taste, slowly drying on exposure, 
forming a transparent mass; completely soluble in 
ether, chloroform or benzol. Dose, 10 to 30 grains. 
Turpentines are stimulant, diuretic, anthel- 
mintic, and hemostatic; in large doses laxative and 
irritant, and externally used are rubefacient and 
antiseptic. Their virtues depend entirely on the 
volatile oil. 
Oil of turpentine is employed externally as a 
rubefacient and counterirritant in many conditions 
producing pain and inflammation. Cloths wrung 
out of hot water and then sprinkled with the oil 
(turpentine stupes) are useful applications in 
sciatica and other neuralgias, lumbago, chronic 
rheumatism, chronic bronchitis, peritonitis with 
tympanites, pleurisy, and renal colic. It is one of 
the most efficient agents in hospital gangrene, 
applied in full strength to the part affected. The 
liniment is in constant use for sprains, neuralgia, 
and other slight local affections. 
Internally it is best employed in ulceration and 
hemorrhage of the intestines and in passive hemor- 
rhages from other organs. Active bleeding with 
a plethoric condition and hematuria are states in 
which it is contraindicated. It is often used with 
ether (1 to 3) in biliary and flatulent colic as an 
anodyne and antispasmodic. 
Preparations.-Oleum Terebinthinae, C10H18, 
commonly called Spirit or Spirits of Turpentine, 
is a volatile oil distilled from turpentine. A thin, 
colorless liquid of characteristic odor and taste; 
soluble in 3 times its volume of alcohol, mixes 
with other volatile and fixed oils, and dissolves 
resins, wax, sulphur, phosphorus and iodin. It 
is a mixture of several hydrocarbons (terpenes), 
each having the same formula as itself. Oleum 
Terebinthinae Rectificatum, prepared by shaking 
oil of turpentine with an equal volume of solution 
of sodium hydroxid, distilling three-fourths, and TUSSOL 
TYMPANITES 
separating. This preparation should always be 
dispensed when oil of turpentine is required for 
internal use. Dose, as a stimulant or diuretic, 
5 to 25 minims, in emulsion 3 to 6 times daily; 
as a cathartic or anthelmintic 4 drams or more, 
combined with other cathartics. A little glycerin 
and oil of gaultheria will disguise the taste. 
Emulsum Olei Terebinthinae has of the rectified 
oil 15, expressed oil of almond 5, syrup 25, acacia 
15, water to 100. Dose, 1/2 to 2 drams. Lini- 
mentum Terebinthinae, Turpentine Liniment, has 
35 parts of the oil of turpentine with 65 of resin 
cerate. 
TUSSOL.-Mandelate of antipyrin. Tussol 
combines the antipyretic, analgesic and sedative 
action of antipyrin with the stimulant action of 
mandelic acid on glandular secretions. It is 
recommended in whooping cough. Dose, 1/2 to 
8 grains according to the age of the patient. 
TWILIGHT SLEEP.-The German word Dam- 
merschlaf (of which "Twilight Sleep" is the equiv- 
alent) is the term used by Krbnig and Gauss of 
Freiburg, to designate a condition of partial 
analgesia with subsequent amnesia of events 
occurring while in this state. The agents employed 
are scopolamine, and morphin or narcophin (a 
mixture of morphin and narcotin meconates). The 
condition is employed for obstetric cases, and it 
has also been used in surgical operations. 
Technic.-All outside stimuli must be mini- 
mized; with this end in view the room is darkened, 
the patient's ears are stopped with cotton, and the 
eyes are lightly bandaged. The drug is withheld 
until labor is well under way. The patient is then 
put to bed, and about 1/130 grain scopolamine 
hydrobromid is injected, with 1/6 grain morphin or 
1/2 grain narcophin. In one hour 1/450 grain 
scopolamine hydrobromid is again injected. Thirty 
minutes later memory tests are made; for instance, 
the patient is asked if she has received any hypo- 
dermatic injections, and how many; some object 
may be brought to her attention, then after an 
interval she is asked whether she has seen it before. 
Injections of scopolamine hydrobromid, 1/450 
grain, are repeated at intervals of 1 1/2 hours or 
longer depending upon the degree of amnesia 
present. The object is, primarily, not to abolish 
pain but to abolish the memory of pain. Water must 
be given freely. 
The fetal heartbeat must be carefully watched, 
and in case of weakening, delivery must be has- 
tened by forceps. Chloroform is used as a re-en- 
forcement just as the head is born. 
Contraindications.-The following are generally 
agreed upon as contraindicating the use of Twilight 
Sleep: 
1. Primary uterine inertia. 
2. History of previous short and easy labors. 
3. Hemorrhage in connection with labor or the 
puerperium. 
4. Weak fetal heart beat. 
5. Eclampsia. 
6. Pelvic contraction. 
Disadvantages.-The second stage of labor is 
prolonged and the use of forceps or the administra- 
tion of pituitrin may be required. The children 
more frequently exhibit delayed respiration and 
marked cyanosis. Mental excitement and restless- 
ness are present in some cases, necessitating re- 
straint and rendering it difficult to maintain asepsis. 
Cases of prolonged drug psychosis due to the 
scopolamine, have been reported. 
Requisites.-A stable solution of scopolamine 
hydrobromid, prepared with mannite, or a fresh 
solution of a reliable tablet must be used. The 
patient must be in a hospital, or under the con- 
stant attendance of the obstetrician and a qual- 
ified nurse. Additional attendants may be re- 
quired to restrain the patient. All preparations 
should be made for rapid delivery in case of need. 
To an impartial observer, over a year after its 
sensational re-introduction to American practice 
(for hyoscin morphin was essentially the same in 
principle), it would seem that many of its erstwhile 
advocates are now limiting its use to patients who 
persist in demanding it after its dangers and dis- 
advantages have been candidly explained. It is 
even stated that in fairness we must not promise 
the patient a painless labor. The fact is better 
realized that narcosis and analgesia are inconstant 
and incidental results of the treatment; in a suc- 
cessful case the patient may complain bitterly 
of pain, during the labor, but after the birth she 
will deny having ever experienced it. In 10 to 
15 percent of cases the method is an admitted 
failure. 
TWIN BIRTHS.-See Labor, Pregnancy (Mul- 
tiple). 
TWITCHING.-See Blepharospasm, Chorea, 
Tremor. 
TYMPANIC INFLATION.-See Ear (Examina- 
tion). 
TYMPANITES.-The symptom which is popu- 
larly known as "drum belly," a distention of the ab- 
dominal walls caused by paralysis of the muscular 
coat of the intestines and their inflation with gas. 
In slight degree tympanites accompanies all forms 
of chronic gastric and intestinal disturbance. It 
is due partly to the formation of gas and partly to 
the paralytic condition of the intestinal walls. 
In acute intestinal obstruction and in intussus- 
ception tympanites is not marked. Indeed, in 
the latter disorder there may be marked depression 
and sinking instead of distention due to flatus. In 
peritonitis tympanites may be the occasion not 
only of discomfort, but also of danger to life. In 
intestinal tuberculosis tympanites is due to loss 
of tone of the muscular walls of the gut; and it 
may also occur in long-standing cases in which 
adhesions have taken place between the visceral 
and parietal layers. In typhoid fever tympanites 
of moderate grade is a frequent but not a serious 
symptom, but it is of grave import when excessive. 
The walls of the gut become infiltrated with serum, 
and gas accumulates in the small and large 
intestines, particularly in the latter. When 
extreme, the diaphragm is compressed and the 
action of the heart and lungs is very much 
interfered with. Tympanites undoubtedly favors 
perforation. 
Treatment must be directed to the cause. 
When due to obstruction by cancer, operation TYMPANUM 
TYPHOID FEVER 
being contraindicated, the aspirating needle may 
be plunged through the abdominal wall. This 
procedure is not altogether free from danger, and, 
as a rule, affords little relief. The long tube 
introduced high up into the rectum is almost use- 
less. It may be necessary to make an opening in 
the middle line of the abdomen and to secure the 
first coil of distended intestine and open it, leaving 
it in situ in the abdominal wall. Of drugs, 
asafetida is used as a carminative, affecting 
chiefly the lower bowel. In the intestinal in- 
digestion of the aged, when associated with flat- 
ulence, and in the flatulent colic of children, 
asafetida is efficient. By rectal injection this 
drug is of much value in the tympanites of children 
and in that of adults in typhoid fever. The 
following pill is useful for flatulence in the aged: 
1$. Extract of nux vomica, gr. v 
Extract of physostigma, gr. iij 
Asafetida, gr. xl. 
Divide into 20 pills. Give 1 pill night and 
morning. 
For speedy results in nonchronic cases, 30 
minims of the aromatic spirit of ammonia may be 
tried, or brandy may be given. Hoffmann's 
anodyne, in combination with the compound 
tincture of cardamom, is often effective. Turpen- 
tine, creosote (alone or combined with galbanum), 
musk, ammonia, alcohol, charcoal, ginger, capsi- 
cum, cajuput, and peppermint may be adminis- 
tered. 
TYMPANUM.-See Ear (Diseases). 
TYPHLITIS.-A catarrhal inflammation of the 
mucous membrane of the cecum and ascending 
colon; it is characterized by pain, tenderness, 
constipation, and in certain cases by a character- 
istic vomiting. In the majority of cases it is due 
to the accumulation of feces in the cecum. 
Symptoms.-Pain and tenderness in the right 
iliac fossa and along the ascending colon, with 
some prominence of this region; the bowels are 
distended with gas (meteorism) and are usually 
constipated, or small liquid stools may occur from 
time to time, due to the accumulation of hardened 
feces in the sacculated periphery of the cecum, 
leaving a central canal, through which the liquid 
contents of the upper bowel can pass. In severe 
cases the local pain, tenderness and swelling are 
greater and there is impaction of feces. There are 
decided fever, restlessness, and also nausea and 
vomiting. The vomited matters consist at first 
of the contents of the stomach, then of the duo- 
denum, with bilious matter, and, ultimately, if 
the impaction persists, of material having the 
odor of feces. With these symptoms occurs great 
depression of the vital powers. Peritonitis is 
finally developed by contiguity of tissue or by 
rupture of the bowel. 
The temperature, even in mild cases, is one or 
two degrees above the normal, and in some cases 
an eruption is seen upon the abdomen, consisting 
of one or two dark red spots the size of a pinhead, 
which are of short life and disappear on pressure. 
The mild form lasts about one week. The 
severe form may terminate in subacute peritonitis, 
continuing about two weeks. 
Diagnosis.-The mild form is distinguished 
from other intestinal affections by the localized 
pain, by tenderness and prominence, and by the 
constipation. 
The severe form can only be distinguished from 
the other forms of intestinal obstruction by the 
history of the case and of the attack, and by the 
results of treatment. 
The prognosis in the mild form is favorable. In 
the severe form it is grave, although not necessar- 
ily hopeless. 
Treatment.-The patient should be kept in bed, 
and receive a strictly milk diet in very limited 
amounts for a few days. If the pain and suffer- 
ing are intense, a hypodermic injection of morphin 
should be immediately administered. 
For the removal of the impacted feces, which in 
the majority of cases is the cause of the inflamma- 
tion, use the following: 
I|. Magnesium sulphate, 3 xij 
Dilute sulphuric acid, 5 ij 
Tincture of opium, 3 iv to vj 
Spirit of chloroform, 3 ij 
Peppermint water, enough 
to make 3 iij. 
One teaspoonful every hour, diluted. 
The following should be useful in some cases: 
1$. Calomel, gr. ij 
Sodium bicarbonate, gr. xxiv 
Sugar of milk, 3 ss. 
Make 12 powders. Give 1 every hour until 
12 have been taken, followed by 4 ounces of 
hot Hunyadi J^nos water. 
In severe cases opium is to be immediately given, 
by hypodermic injections of morphin guarded 
with atropin, continued until all symptoms of 
inflammation have subsided, when attempts to 
remove the accumulated feces may be made by 
irrigation of the bowel with warm soapsuds and 
by the cautious administration of magnesium 
sulphate in dram doses every 2 hours. Locally, 
hot, dry applications or the ice-bag may be used. 
See Appendicitis. 
TYPHOID FEVER (Enteric Fever). Definition. 
-A general infection, caused by the bacillus 
typhosus, characterized anatomically by hyper- 
plasia and ulceration of the lymph follicles of the 
intestines, swelling of the mesenteric glands and 
spleen, and parenchymatous changes in the other 
organs. 
Period of Incubation.-From 8 to 23 days. 
Etiology.-The disease is widely distributed 
throughout the world, and especially prevails 
in temperate climates. Contaminated water, 
milk or food such as oysters bedded near sewer 
exits, or green vegetables fertilized by means of 
sewage or washed with infected water, and de- 
fective drainage are the most important factors in 
the etiology. It is most prevalent in the autumn 
months. Young adults are most prone to be 
attacked. Males and females are equally affected. 
Idiosyncrasy plays a role in some families. The TYPHOID FEVER 
TYPHOID FEVER 
typhoid ''carrier" is an important factor in the 
dissemination of the disease. 
Description of Bacillus Typhosus.-A rather 
short, thick, flagellated, motile bacillus with 
rounded ends; it grows readily on nutritive me- 
dia, and can be distinguished from the colon 
bacillus, which it closely resembles. It stains 
well with the ordinary anilin dyes. To stain for 
bacilli in tissues, allow the specimen to remain in 
Loeffler's alkaline methylene-blue solution for from 
15 minutes to 24 hours, wash in water, dehydrate 
rapidly in alcohol, clear up in xylol, and mount in 
Canada balsam. 
The Bacilli Outside the Body.-In drinking- 
water'they retain theif vitality for weeks, and in 
the soil for months. They are not destroyed by 
freezing. 
Modes of Conveyance.-By "food, fingers, and 
flies" mainly. 
Modes of Infection.-While infection usually 
takes place through the intestines, the researches of 
Chiari, Kraus, Hodenpyl, Flexner, and others, 
show that even in the early stages the bacilli are 
widely distributed throughout the system. 
In the immense majority of cases of typhoid 
fever marked enteric lesions are present, but 
exceptionally the disease is one in which there is 
vessels become choked, there is a condition of 
anemic necrosis, and sloughs form, which are sub- 
sequently thrown off. The process has a pre- 
dilection for the area nearest the ileocecal valve. 
Ulceration.-The separation of the necrotic 
tissue-the sloughing-is gradually effected from 
the edges inward, and results in the formation of 
an ovoid ulcer, the floor of which is formed by 
the submucosa and muscularis. The edges are 
usually swollen, soft, sometimes congested, and 
often undermined. These ulcers of the intestine 
are characteristic, and can be differentiated from 
tubercular ulcers in the same situation, as follows: 
In the typhoid ulcer (1) the main axis of the ulcer 
lies parallel with that of the intestine; (2) it lies 
opposite to the mesenteric attachment; (3) it has 
smooth floor and undermined edges; (4) it com- 
monly leads to perforation. In tubercular ulcer 
(1) the long axis of the ulcer lies at right angles to 
that of the intestine; (2) it is not necessarily 
situated opposite the mesenteric attachment; (3) 
its floor is not smooth nor are its edges under- 
mined, but rather funnel-shaped and irregular; 
(4) it is not apt to perforate, but it does not tend 
to heal, rather to spread. 
Healing begins by the formation of granulation 
tissue at the base of the ulcer. The mucosa ex- 
tends from the edge, and a new growth of epithe- 
lium is formed. Later the glandular elements are 
restored. 
Perforation of the Bowel.-In 2000 autopsies 
performed in Munich perforation occurred in 114 
instances, or 5.7 percent. In 80 autopsies per- 
formed at the Montreal General Hospital per- 
foration was present in 22 cases. Perforation gen- 
erally occurs within the last foot of the ileum. 
Multiple perforations may be present. 
The mesenteric glands are greatly swollen, and 
spots of necrosis or suppuration may occur. 
The spleen is invariably enlarged in the early 
stages of the disease, and rupture may occur 
spontaneously or as the result of trauma. 
The liver shows signs of parenchymatous de- 
generation. Early in the disease it is hyperemic, 
and in a majority of instances is slightly swollen. 
Microscopically, the cells are very granular and are 
loaded with fat. 
The gall-bladder not infrequently contains a 
pure culture of the bacilli, and acute cholecystitis 
is not very uncommon. 
The kidneys show a degree of cloudy swelling, 
with granular degeneration of the cells of the con- 
voluted tubules. 
Ulceration of the larynx has been noted in a con- 
siderable number of cases. 
Changes in the Circulatory System.-Endocar- 
ditis is rare, as is also pericarditis. Myocarditis is 
more frequent. Inflammation of the arteries, with 
formation of thrombi, may take place, and bacilli 
have been found in them. Thrombosis of the 
femoral vein is common; most frequently on the 
left side. 
Disposition of Bacilli in the System.-Typhoid 
bacilli have been found in the blood, in the spleen, 
in the liver, in the vegetations on the valve leaflets, 
in thrombi, and in the exudation from the men- 
Bacillus Typhosus. 
Pure culture containing a few irregular forms.-(.Coplin.) 
a general infection, without special local manifesta- 
tions; or the localizations may be other than 
enteric; or there may be a mixed infection of the 
typhoid bacillus with the colon bacillus, strep- 
tococcus, staphylococcus, pneumococcus, or ba- 
cillus of tuberculosis. In the tropics, more rarely 
in temperate regions, typhoid fever occurs in 
persons already affected with malaria. 
Morbid Anatomy. Intestines. Hyperplasia.- 
The glands of Peyer in the jejunum and ileum, and 
to a variable extent those in the large intestine, 
are swollen, grayish-white in color, and may pro- 
ject to a distance of from 3 to 5 mm. This con- 
dition may disappear by a fatty and granular 
change in the cells, which are destroyed and sub- 
sequently absorbed, or it may pass on to- 
Necrosis and Sloughing.-When the hyperplasia 
of the lymph follicles reaches a certain stage, 
resolution is no longer possible. The blood- TYPHOID FEVER 
TYPHOID FEVER 
inges. They are always present in the affected 
areas of the bowel. 
Symptoms. First Week.-The onset is rarely 
abrupt. Prodromal symptoms are generally pres- 
ent over a period of several days, and are mani- 
fested by a feeling of restlessness, vague pains, 
faint rigors, nausea, loss of appetite, pains in the 
head, back, and limbs, and nose-bleeding. The 
bowels may be constipated or diarrhea may be 
present; most frequently the latter. 
There is a steady rise of temperature to 103° or 
104° F. The pulse is rapid (100 to 110), full in 
volume, of low tension, and dicrotic. At this 
time there may be mental confusion, particularly 
at night. Toward the end of the first week the 
spleen becomes enlarged and a rash appears in 
the form of discrete, rose-colored spots, slightly 
elevated, and first seen on the abdomen. They 
disappear on slight pressure. The spots may also 
be found on the chest and back, and occasionally 
on the limbs and face. 
Second Week.-The fever becomes higher or 
remains steady, the pulse is rapid and loses its 
dicrotic character, the face has a dull appearance, 
mental activity is slow, and the lips and tongue 
may get dry. The abdominal symptoms, if 
present, are diarrhea, tympanites, and tenderness. 
Hemorrhage or perforation may occur. In mild 
cases there is a gradual decline of the fever to the 
normal after the fourteenth day. 
Third Week.-The temperature shows marked 
morning remissions, with a gradual decline. The 
pulse ranges from 110 to 130. Diarrhea and 
meteorism may now occur for the first time, and 
there is a special liability to hemorrhage and 
perforation. 
Fourth Week.-The morning temperature has 
usually reached normal, but there is an evening 
exacerbation of one or more degrees, the diarrhea 
stops, the tongue becomes clean, and there is a 
craving for food. 
The fourth week generally marks the beginning 
of convalescence. In aggravated cases the disease 
may continue over a period of 5, 6, or even 8 
weeks. 
The Fever.-In the stage of the invasion the 
fever steadily rises during the first 5 or 6 days. 
The evening temperature is about 1 degree or 11 / 2 
degrees higher than the morning record. In 
certain instances there may be a difference of 3 
or even 4 degrees. The temperature falls by 
lysis, and is not considered normal until the 
evening record is at 98.2° F. 
A fever with regular remissions is considered of 
favorable prognosis. A sudden drop in the tem- 
perature may mark the occurrence of hemorrhage 
or of perforation of the bowel. 
Post-typhoid Elevations. The Fever of Convales- 
cence.-Frequently, after the temperature has re- 
mained normal for several days there is a sudden 
rise (102° to 103° F.), and a drop at the end of 
24 or 48 hours. It is generally dependent upon 
errors in diet, constipation, or excitement brought 
on by visits of friends. It may, however, inaug- 
urate a relapse, or mark the onset of a complica- 
tion. The fever of relapse partakes of the same 
nature as in the original attack, but is milder, and 
rarely continues longer than 10 days or 2 weeks. 
The Skin.-The characteristic eruption of 
typhoid fever has been described. Sometimes 
there may be areas of erythema, confined to the 
abdomen or chest. Sudamina are very common, 
and result from profuse sweating. The facial 
expression is dull and listless, but differs from that 
of malarial fever, as the anemia is not so marked. 
The pupils are usually dilated. 
Respiratory Symptoms.-Respirations are some- 
what hurried, and frequently bronchial rales are 
heard. There may be an early acute bronchitis. 
Circulatory Symptoms.-Dicrotic pulse (in first 
week), of low tension; heart-sounds at first clear 
and loud, but later the first sound becomes feeble, 
and along the left sternal margin or at the apex a 
soft systolic murmur may be heard. 
Gastric Symptoms.-Loss of appetite is an early 
symptom; rarely nausea and vomiting occur. The 
edges of the tongue may be reddened, while the 
center is coated. 
Intestinal Symptoms.-Diarrhea is present in 
from 25 to 30 percent of the cases. It is a mistake 
to believe that it is an invariable symptom in 
typhoid. Abdominal tenderness and distention 
and gurgling in the right iliac fossa occur in a large 
proportion of cases. Diarrhea is most common 
toward the end of the first week, but it may not 
occur until the second or even the third week. 
The stools, which range from 3 to 10 within the 24 
hours, are thin, offensive, granular, and resemble 
pea-soup. On standing they separate into a thin, 
serous layer, containing albumin and salts, and a 
lower stratum, consisting of epithelial debris, par- 
ticles of undigested food, and triple phosphates. 
Blood-corpuscles may be found. 
Nervous Symptoms.-Headache, slight deafness, 
and mental torpor may be present in the early 
stages; and later, in severe cases, profound stupor, 
muttering delirium, subsultus tendinum, and 
coma-vigil. 
The blood presents no material changes until 
about the third week. At this time there is a 
reduction in the number of red corpuscles, which 
may fall as low as 1,300,000 to the cubic millimeter 
(Thayer), together with the hemoglobin, which is 
reduced in a greater relative proportion than the 
red cells. The absence of leukocytosis may aid 
in differentiating typhoid from septic and acute 
nflammatory processes. 
The Urine.-Retention of urine is an early symp- 
tom in many cases. In the early stages, as in other 
febrile conditions, the quantity is reduced and of 
a higher color; later it becomes more abundant 
and possesses a lighter tint. Ehrlich has described 
a reaction that he believes is rarely met with ex- 
cept in typhoid fever. This so-called diazo- 
reaction is produced as follows: Two solutions 
are employed, kept in separate bottles, one con- 
taining a saturated solution of sulphanilic acid in 
a solution of hydrochloric acid (50 c.c. to 1000); 
the other a 0.5 percent solution of sodium nitrite. 
To make the test, a few cubic centimeters of urine 
are placed in a small test-tube with an equal 
quantity of a mixture of the solution of sulphanilic TYPHOID FEVER 
TYPHOID FEVER 
acid (40 c.c.) and the sodium nitrite (1 c.c.), 
the whole being thoroughly shaken. One cubic 
centimeter of ammonia is then allowed to flow 
carefully down the side of the tube, forming a 
colorless zone above the yellow urine, and at the 
junction of the two a deep brownish-red ring will 
be seen if the reaction is present. With normal 
urine a lighter ring is produced, without a shade 
of red. It is very important to bear in mind that 
countless millions of bacilli may be present in the 
urine, which should always be disinfected. 
Convalescence ordinarily begins at the fourth 
week. In certain cases it may be protracted, and 
may be marked by falling of the hair, great en- 
feeblement of the system, and transitory mental 
derangement. 
Varieties of Typhoid Fever. 1. Mild and Abor- 
tive Forms.-In the mild form the symptoms are 
similar in kind, but less intense, than in the 
graver attacks, although the onset may be sudden 
and severe. The spleen is enlarged, and rose 
spots are marked. Diarrhea may or may not be 
present. The duration is about 8 to 10 days. 
In the abortive form the symptoms of onset may 
be marked, with shivering and fever of 103° F., or 
higher. The date of onset is definite. Rose spots 
may develop from the second to the fifth day. At 
the end of the first week or the beginning of the 
second week convalescence is established. 
2. The grave form is usually characterized by 
high fever and pronounced symptoms affecting 
the nervous system, the gastrointestinal tract, and 
the renal or pulmonary organs. 
3. Latent or Ambulatory Form.-In this variety 
the onset is very mild, and the patient does not 
feel ill enough to go to bed. It is marked by 
languor and perhaps slight diarrhea. In certain 
cases delirium may be present. Death is common 
from neglect of treatment. 
4. Hemorrhagic Form. 
5. A febrile form recognized by Liebermeister is 
very. rare. 
Typhoid Fever in Children.-Infants under the 
age of 2 years are rarely attacked; cases are not in- 
frequent in children between the second and tenth 
years. Epistaxis rarely occurs; the rise in tem- 
perature is gradual; bronchial catarrh is often 
observed; nervous symptoms are prominent, and 
are manifested by wakefulness and delirium; 
diarrhea is often absent; the eruption is slight; the 
abdominal symptoms are mild; and perforation 
rarely occurs. 
Typhoid Fever in the Aged.-After the age of 40 
the disease is very rare. 
Typhoid fever is rare in pregnant women. Abor- 
tion or premature delivery usually occurs in the 
second week of the disease. The mortality is high 
(17 percent). 
Relapse is prone to occur. The true relapse sets 
in after complete defervescence of the fever and 
follows a somewhat milder course than the original 
type, and lasts from 2 to 3 weeks. Two, 3, or 
even 4 relapses may occur. The condition de- 
pends upon a reinfection, probably due to errors 
in diet, to constipation, or to overexertion of any 
kind. 
Complications.-Hemorrhage from the bowels, a 
serious complication, occurs in from 3 to 5 percent 
of all cases, most commonly between the end of 
the second and the beginning of the fourth week- 
at the time the sloughs separate. The onset is 
often marked by a rapid fall in the temperature 
and by symptoms of collapse, both of which may 
occur some time before the blood makes its appear- 
ance in the stool. The mortality is from 30 to 50 
percent of the cases. 
Perforation occurs in from 5 to 6 percent of all 
cases, and is more frequent in men than in women. 
The peritonitis that it causes is marked by a sudden 
acute pain in the abdomen and by symptoms of 
collapse, followed by marked tenderness and rig- 
idity of the abdominal walls, vomiting, a pinched 
expression of the face, dyspnea, and a small, rapid 
pulse. Great abdominal distention is usually 
present. 
Peritonitis without perforation may occur by 
extension of the inflammation to the peritoneum 
surrounding the intestine. 
Pneumonia.-Pneumonia and hypostatic con- 
gestion occur in about 8 percent of the cases. 
Bed-sores are less frequently encountered than 
formerly, owing to the proper nursing now general. 
Thrombi in the veins occur in about 1 percent of 
the cases, and the left femoral vein is usually 
affected. Thrombosis is indicated by enlarge- 
ment and edema of the limb affected. 
Among other complications are excessive diar- 
rhea, meteorism, gangrene, parotitis, pharyngitis, 
endocarditis, bronchitis, nephritis, and pyuria. 
The Widal reaction is as follows: 
Macroscopic.-The blood or serum to be tested 
is added either "to a young bouillon culture of 
the typhoid bacillus or to sterile bouillon, which 
is then at once inoculated with the bacillus. In 
the former case the reaction with typhoid serum 
appears usually within 2 or 3 hours, and consists 
in clarification of the previously turbid fluid and 
the formation of a clumpy sediment composed of 
accumulated bacilli. In the latter case the tube is 
placed in the incubator, and within 15 hours the 
reaction is manifested by growth of the bacilli in 
the form of a sediment at the bottom of the tube, 
the fluid remaining nearly or quite clear." 
Microscopic Test.-The blood or serum is mixed 
with " a young bouillon culture or with a suspen- 
sion in bouillon or salt solu- 
tion of a fresh growth of the 
typhoid bacillus, and a drop 
or two of the mixture is ex- 
amined at once under the 
microscope. With a dilu- 
tion of 1:10 this microscopic 
typhoid reaction appears, as 
a rule, immediately or with- 
in a few minutes, and is evi- 
denced by loss of motility 
and by clumping of the bacilli 
into masses of various sizes 
and shapes." When this 
reaction occurs, it is spoken 
of as a "positive reaction"; and when not pres- 
ent, it is said to be "negative." 
Typhoid Agglutination 
Test. 
Upper segment shows 
the freely moving germs. 
The lower the typical 
" clumping."-{Greene.) TYPHOID FEVER 
TYPHOID FEVER 
The reaction is present in about 95 percent of 
cases. 
Prognosis.-The mortality in private practice is 
from 5 to 12 percent, and in hospitals it is from 7 
to 20 percent. Unfavorable symptoms are hemor- 
rhage, delirium, meteorism, excessive diarrhea, 
and suppression of urine. 
Prophylactic Treatment. Antityphoid Inocula- 
tion.-A. E. Wright has prepared a vaccine a, 
dead sterile culture of the typhoid bacillus, that 
has been used extensively in the British and 
United States armies; and that gives immunity 
for 2 to 3 years, while at the same time it is 
absolutely innocuous. 
Two or three injections should be made at 
intervals of 10 days, the first of 500 millions, the 
second and third of 1000 millions each. 
For the prevention of the resulting lessened 
coagulability of the blood Wright advises 30 to 40 
grains of calcium chlorid, and alcohol should be 
forbidden. It has been found to diminish both 
the incidence and the mortality of typhoid fever. 
Leishman reports: "In 5473 soldiers vaccinated 
against the disease, 21 took it and 2 died; in 6610 
soldiers practically under the same conditions, 
who were not vaccinated, there were 187 cases 
and 26 deaths; that is, among the vaccinated sol- 
diers there were 3.8 cases per thousand, and 
among the unvaccinated 28.3 per thousand." It 
is recommended for troops, especially when concen- 
trated in camps, for nurses and physicians, and all 
persons exposed in time of epidemic. Castellani 
advises for prophylaxis an inoculation of dead 
culture to be followed a week later by the in- 
oculation of an attenuated live culture, main- 
taining that the degree of immunization obtained 
by the latter is greater, while at the same time the 
reaction is not severe and the person does not 
become a " carrier." 
In the United States army over 8500 persons 
had been inoculated up to June, 1910, and none 
of them contracted typhoid, although among the 
unprotected in the same period of time there oc- 
curred more than 200 cases. 
Under conditions of careful asepsis the injection 
is made subcutaneously into the arm at the in- 
sertion of the deltoid muscle, preferably at about 
4 p. m., so that the greater part of the reaction 
may take place before morning. The reaction is 
in most cases very slight; severe general reactions 
occurring with headache, backache, vomiting, 
nausea, and is in every case entirely over in 48 
hours. During this period it is best to abstain 
from active exercise. 
The following procedures, suggested by Gilman 
Thompson, should be carried out in hospital 
practice, and, with modifications, in private 
houses: 
1. The best disinfectants of typhoid urine and 
stools for practical use are: (a) 1:500 acidulated 
solution of corrosive sublimate; (b) a 1:10 crude 
carbolic acid solution; (c) chlorinated lime. 
2. Owing to the possibility of inj ury to plumbing, 
the carbolic acid solution is preferable wherever 
plumbing is concerned. The lime is best for 
country use, in privies and trenches. 
3. The disinfectant should be thoroughly mixed 
with the stool, and left in contact with it for fully 
2 hours. Enough of the disinfectant must be 
added completely to cover the stool with the solu- 
tion. 
4. The bed-pan should be kept filled at all times 
with at least a pint of the disinfectant, into which 
the stool is at once discharged, and should be 
cleaned with scalding water and one of the dis- 
infecting solutions. 
5. Rectal thermometers, syringes, tubes, and all 
utensils coming in contact with any of the fecal 
matter must be disinfected with the corrosive 
sublimate or carbolic acid solution. 
6. After each stool the patient's perineum and 
the adjacent parts should be washed and sponged 
with a 1:2000 corrosive sublimate solution. 
7. Nurses and attendants should be cautioned to 
wash their hands thoroughly, and to immerse them 
in a 1:1000 corrosive sublimate solution after 
handling the bed-pan, thermometer, syringe, or 
patient, or after giving sponge or tub-baths. 
8. All linen or bedclothing used by the patient 
should be soaked in 1:20 phenol solution, and sub- 
sequently boiled for fully 2 hours. 
9. Disinfection of the stools should be begun as 
soon as the diagnosis of enteric fever is established, 
and should be continued for 10 days after the 
temperature has remained normal. 
10. In localities where a proper drainage system 
is lacking, the stools should either be mixed with 
sawdust and cremated or buried in a trench 4 feet 
deep after being covered with chlorid of lime. 
When epidemics are prevalent, the drinking- 
water and milk should be boiled. 
Important for the patient and for the public is 
the removal of typhoid bacilli from the urine by 
the administration of urotropin in doses of 7 1/2 
grains three times a day beginning the third week 
at least, and continued for several weeks during 
convalescence. 
General Treatment.-The physician and attend- 
ants should ever keep in mind the fact that each 
individual case of typhoid fever is a focus for the 
spread of the disease. To carry out effective 
measures of prophylaxis is quite as much a part 
of the physician's duty as is the care of the 
patient. 
General Management.-Careful nursing and a 
regulated diet are the essentials in a vast majority 
of cases. The patient should be kept in a well- 
ventilated room, strictly confined to bed from the 
onset, and remain there until the evening tempera- 
ture has been normal for a period of at least 8 days. 
The constant use of the bed-pan should be strictly 
enjoined. 
Diet.-A liquid diet should be begun at the onset, 
and should be continued throughout the course of 
the disease. Milk is the best food. If not well 
digested, a tablespoonful of lime-water may be 
added to each glass of milk, or it may be pepto- 
nized. The stools should be frequently examined, 
to see if they contain much fat. Other varieties of 
liquid foods may be given, such as strained soups, 
mutton or chicken broth, consomme, barley gruel, 
albumen water, and beef-juice. A pleasant fresh TYPHOID FEVER 
TYPHOID FEVER 
beef-extract may be made in the following manner: 
A thick piece of steak is seasoned with a small 
amount of butter, pepper, and salt, and subse- 
quently placed on the top of a hot stove for a 
minute or two; it is then turned quickly to the 
opposite side, and allowed to remain until slightly 
browned; it is then cut into small pieces, to be 
masticated by the patient, only permitting the 
liquid portion to be swallowed. This diet may be 
allowed to patients in private practice when the 
persons are well known. In hospital practice it 
may prove dangerous, from the fact that solid 
particles might be swallowed surreptitiously. If 
diarrhea is present, soups, beef-juice, and beef- 
extracts may aggravate the condition, and milk, 
strained gruel, and barley-water should be sub- 
stituted. 
Plenty of cold water should be given to the 
patient. Fruits should not be given, but the 
juice of an orange or of a lemon may be taken at 
intervals. 
Typhoid patients should be fed every 3 hours 
throughout the day. If there is great exhaustion, 
milk or liquid foods may also be given once or 
twice during the night, but in mild cases this is 
not necessary. 
The Coleman-Shaffer High Calory Diet.-This 
has been tried, with success, in several cases of 
typhoid fever, and has been suggested in other 
fevers as well. We append herewith the conclu- 
sions of Dr. Coleman, with an account of the admin- 
istration of the diet 
"Conclusions.-(1) None of the older diets for 
typhoid fever furnishes the patient with sufficient 
energy for his metabolic exchanges. Therefore a 
patient taking any of these diets is compelled to live 
in part upon his own tissues. 
" (2) The amount of food which a patient re- 
quires can be determined only by his individual 
needs. The clinical guides to these needs are the 
weight of the patient and the state of his appetite. 
A patient who is losing weight should be given 
more food if he can digest and absorb it. A 
patient who is hungry should be given sufficient 
food to appease his appetite. In the early stage of 
severe cases it is always difficult to give more than 
3000 calories a day; in the steep-curve period and in 
convalescence, patients take readily from 4000 to 
6000 calories a day. 
" (3) If any article of food causes persistent dis- 
turbances of digestion, the quantity given should 
be diminished, or the food should be stopped; 
otherwise the object of the high calory diet, the 
maintenance of the patient's nutrition, is defeated. 
If a patient cannot take all the food he requires, he 
should be given all he can digest and absorb. 
" (4) Carbohydrates should furnish the greater 
part of the energy of the diet. The daily protein 
ration should not be below 62 grams, nor greatly 
exceed 94 grams. Clinical evidence indicates that 
a diet rich in fat may be taken by typhoid fever 
patients with benefit. Fat has furnished in some 
cases from one-third to one-half of the total energy 
of the food. 
" (5) In the cases studied, the high calory diet 
has apparently modified the course of the disease, 
shortened convalescence, and reduced the mor- 
tality. 
" Details of Administration.-The successful 
administration of the high calory diet depends upon 
unremitting attention to detail. It is a good plan 
to make a frank statement to the patient regarding 
the object of the diet whenever, in the opinion of 
the physician, this can be done. However, it is 
not always wise to enter too fully into particulars. 
Very often I tell patients that the more they eat, 
the sooner they will get well, and the effect of the 
suggestion upon the quantity of food which they 
will take is sometimes surprising. I tell every 
patient who is capable of appreciating the advice, 
to ask the nurse for more food if he wants it, 
and I tell the nurse to give the patient all the food 
he can digest and absorb. 
"Typhoid fever patients cannot all be fed alike. 
Their preferences for and idiosyncrasies to foods 
are not removed by the fever. Yet often the judi- 
cious substitution of one article of food or dish for 
another will increase the fuel value of the diet by 
several hundred calories. Sometimes patients who 
complain that the milk is too sweet when it con- 
tains one-half to one ounce of milk sugar will take 
eagerly from two to four ounces of milk sugar in 
custard, ice cream, or lemonade. As in every 
other illness, the physician should permit as great 
variety of foods as is consistent with the patient's 
wellbeing. 
"Ordinarily, when a patient first comes under 
observation he is put upon plain milk for a day or 
two. The subsequent procedure depends upon the 
patient's condition; that is, whether he is suffering 
from a mild or severe attack of the disease. In the 
former case he may be allowed foods which require 
mastication; in the latter, the diet should be liquid. 
"Foods and Their Calory Values.-All of 
the foods and recipes which follow have been given 
thorough trial, and are recommended with confi- 
dence for appropriate cases. 
Name. 
Amount. 
Calories. 
Apple sauce 
1 ounce 
30 
Bread 
Average slice (33 grams) 
. 80 
Butter 
1 pat (1/3 ounce) 
80 
Cereal (cooked) 
1 heaping tablespoonful (1 1/2) 
Crackers 
ounces) 
. 50 
1 ounce 
. 114 
Cream (20%) 
1 ounce 
60 
Egg 
1 (2 ounces) 
. 80 
Egg, white 
1 
30 
Egg, yolk 
1 
. 50 
Lactose 
1 tablespoonful (9 grams) 
36 
Milk (whole) 
(1 pint 350) 1 ounce 
. 20 
Potato (whole) 
1 medium 
. 90 
Potato (mashed) 
1 tablespoonful 
70 
Rice (boiled) 
1 tablespoonful 
. 60 
Sugar, cane 
1 lump 
16 
Sugar, milk 
1 tablespoonful (9 grams) 
. 36 
Toast 
Average slice 
. 80 
"Rubner's figures for calculating the calory 
values of the different foodstuffs will be found use- 
ful: 1 gram pure protein furnishes 4.1 calories; 
1 gram pure carbohydrate furnishes 4.1 calories £1 
gram pure fat furnishes 9.3 calories. Nitrogen 
multiplied by 6.25 equals protein. 
"Food Combinations and Recipes.-For the 
convenience of those desiring to use the high 
calory diet, the following combinations of foods are TYPHOID FEVER 
TYPHOID FEVER 
given. They are most useful in the early stages of 
the disease, or in the case of patients who are un- 
able to take solid food. 
A thorough sponge bath should require a period 
of not less than 15 minutes. When from any 
cause a full bath cannot be given, sponging with 
ice-cold water may be used. It is specially 
valuable in the case of children and for delicate 
persons. At times it may be less objectionable to 
sponge one extremity at a time; then the abdomen 
and back, in regular order. 
The cold pack is of special service in cases with 
pronounced nervous symptoms. The patient 
should be wrapped in a sheet wrung out of water 
at 60° or 65° F.; cold water is then sprinkled over 
the body with an ordinary watering-pot or a 
similar utensil. 
The Bath (Brand Method).-The tub should be 
of such dimensions that the entire body except the 
head may be immersed. It seems best to give 
the bath every third hour when the temperature 
rises above 102.5° F. The temperature of the 
water at the beginning of the bath should be 
about 70° F., and it should be kept at this point by 
the addition of pieces of ice from time to time. 
The duration of the bath depends upon the height 
of the fever and upon individual susceptibility. 
In the majority of instances the duration varies 
from 15 to 20 minutes. When the colder (70° F.) 
bath is not borne well, it may be best to start with 
a higher temperature (80°-90° F.), and gradually 
to lower it by the addition of ice. After the first 
or second bath less objection is usually en- 
countered. 
The tub should be wheeled to the bedside, and 
after enveloping the body (in the case of women) 
in a sheet, two assistants gradually lower the 
patient into the water. As soon as the body 
(except the head) has been immersed, the head 
should be sponged, and afterward should be kept 
cool. From the moment the patient is placed in 
the water, and in order to prevent chilling, shiver- 
ing, and cyanosis, and to stimulate the circulation, 
the extremities and trunk should be constantly 
rubbed, paying especial attention to the feet and 
hands, which first feel the effects of cold. The 
abdomen may be rubbed only lightly or not at all. 
After removal from the bath the patient should be 
wrapped in blankets, and, if necessary, hot-water 
bottles or bags containing hot water may be 
applied to the extremities. 
In private practice a substitute for the tub may 
be devised as follows: Place a quilt or blanket on a 
cot, cover with a piece of thick black oilcloth, and 
over this place a sheet; upon the latter the patient 
may be placed, and the bath may then be con- 
ducted as described. It will be of great advantage 
to elevate the end of the cot upon which the head 
rests, in order to assist drainage into a receptacle 
placed at the foot. 
Contraindications to the bath are peritonitis and 
hemorrhage. Pregnancy, bronchitis, and pneu- 
monia are not contraindications. 
Advantages of the Bath.-(1) The fever is re- 
duced; (2) the intellect becomes clearer, stupor is 
lessened, and the muscular twitchings disappear; 
(3) there is a general tonic action on the nervous 
system, and particularly on the heart; (4) insomnia 
is lessened, the patient usually falling asleep for 
For 1000 calories a day: 
Milk, 1 quart (1000 c.c.) 
Cream, 1 2/3 ounces (50 c.c.) 
Lactose, 1 2/3 ounces (50 grams) 
Calories 
700 
100 
200 
This furnishes 8 feedings, each containing: 
Milk, 4 ounces 
80 
Cream, 2 drams 
15 
Lactose, 6 grams 
24 
For 1500 calories a day: 
Milk, 1 1/2 quarts (1500 c.c.) 
.. 1000 
Cream, 1 2/3 ounces 
100 
Lactose, 3 1/3 ounces (100 grams) 
400 
This furnishes 6 feedings, each containing: 
Milk, 8 ounces 
160 
Cream, 2 drams 
15 
Lactose, 16 grams 
64 
For 2000 calories a day: 
Milk, 1 1/2 quarts 
.. 1000 
Cream, 8 ounces (240 c.c.) 
500 
Lactose, 4 ounces (125 grams) 
500 
This furnishes 7 feedings, each containing: 
Milk, 7 ounces 
140 
Cream, 1 ounce 
60 
Lactose, 18 grams 
72 
For 2500 calories a day: 
Milk, 1 1/2 quarts 
.. 1000 
Cream, 8 ounces 
500 
Lactose, 8 ounces (250 grams) 
. . 1000 
This furnishes 7 feedings, each containing: 
Milk, 7 ounces 
140 
Cream, 1 ounce 
60 
Lactose, 36 grams* 
144 
For 3000 calories a day: 
Milk, 1 1/2 quarts 
.. 1000 
Cream, 1 pint (480 c.c.) 
.. 1000 
Lactose, 8 ounces 
.. 1000 
This furnishes 8 feedings, each containing: 
Milk, 6 ounces 
120 
Cream, 2 ounces 
120 
Lactose, 1 ounce (30 grams) 
120 
For 3900 calories a day: 
Milk, 1 1/2 quarts. 
.. 1000 
Cream, 1 pint 
.. 1000 
Lactose, 16 ounces (480 grams) 
.. 1900 
This furnishes 8 feedings, each containing: 
Milk, 6 ounces 
120 
Cream, 2 ounces 
120 
Lactose, 2 ounces 
240 
"When the above combinations are employed, it 
is generally desirable to add eggs to the diet in 
order to raise the nitrogen to the desired amount. 
The eggs may be soft-boiled or be shaken up in any 
of the above feedings unless distasteful to the 
patient, though the addition of an egg makes the 
stronger mixtures very rich. Milk toast with the 
addition of butter or cream, is relished by many 
patients. " (From Coleman's article in the American 
Journal of the Medical Sciences, Jan., 1912.) 
Hydrotherapy.-Since 1861 the value of bath- 
ing in fevers has been specially emphasized by 
the late Dr. Brand, of Stettin. Hydrotherapy 
may be carried out in several ways, of which, 
in typhoid fever, the most satisfactory are (1) 
by sponging, (2) the wet pack, and (3) the full 
bath. 
Cold Sponging.-The water may be tepid, cold, 
or ice cold, according to the height of the fever. 
* If this and the following combinations are too sweet, a 
portion of the milk-sugar may be given in some ofherform. TYPHOID FEVER 
TYPHOID FEVER 
several hours after the bath; and (5), most impor- 
tant of all, the mortality is much reduced. 
Under the expectant and general medicinal plans 
of treatment the mortality ranges from 12 to 17 
percent; with the Brand method the mortality in 
many instances has been reduced to a fraction 
above 7 percent. 
Medicinal Treatment.-It should be constantly 
remembered that in the treatment of typhoid fever 
overdrugging does harm. In many cases all that 
may be required is a mild purge at the onset, and 
subsequently a mild diuretic, continued for a day 
or two. The daily use of medicinal antipyretics is 
to be deprecated, from the fact that they are 
depressing, especially to the heart. In obstinate 
cases, when it seems impossible to control the 
temperature by baths, and when they are de- 
manded too frequently, a single dose (5 grains) of 
phenacetin or antipyrin or pyramidon may be 
administered. 
Antiseptic Medication.-Remedies that have 
been recommended are acetozone, beta-naphthol, 
naphthalin, salol, guaiacol, carbolic acid, corrosive 
sublimate, iodin, and calomel. Irrigation of the 
colon has been advised. 
Antitoxin Treatment.-Antityphoid serum has 
been tried by several observers, but the effect has 
been slight. 
Vaccine Therapy.-Recent reports of the use of 
vaccine, preferably autogenous, are very encour- 
aging, most cases having been decidedly benefited. 
Irwin and Houston report the cure of a typhoid 
"carrier" by the injections, sodium lactate being 
also given to make the urine alkaline. At the 
end of the treatment no bacilli were found in 
urine or feces. 
Treatment of Special Symptoms.-The abdominal 
pain and tympanites are best treated with fomenta- 
tions or with turpentine stupes. A flannel roller 
is placed beneath the patient, and then a double 
layer of thin flannel, wrung out of very hot water, 
with a dram of turpentine mixed with the water, 
is applied to the abdomen and covered with the 
ends of the roller. 
Meteorism.-Turpentine internally has been 
highly recommended by the late Dr. George B. 
Wood. It may be given in the form of an emul- 
sion, as follows: 
In some cases soups, beef-extracts, and similar 
foods give rise to the disturbance, and peptonized 
milk should be substituted. The rectal tube may 
give relief; also injection of milk of asafetida 
(5 to 6 ounces). 
Diarrhea.-In this condition no medicines should 
be given unless the stools number 3 or 4 daily. As 
in the case of meteorism, it sometimes ensues from 
animal foods, for which albumin water, barley- 
water, strained gruel, and the like, should be 
substituted. Boiling the milk is frequently all 
that may be necessary. In some cases lime-water 
added to milk will do good. 
I|. Bismuth subnitrate, 3 ijss 
Paregoric, 
Compound .tincture 
of lavender, 
each, 3 j 
Elixir of curacoa, 3 iij 
Water, enough to make 3 iij.' 
Two teaspoonfuls every 3 or 4 hours. 
I). Codein sulphate, gr. iij 
Bismuth sub nitrate, 5 j. 
Divide into 6 capsules. One every 3 hours. 
1$. Dover's powder, 3 ss 
Bismuth subcarbonate, 3 j. 
Divide into 6 powders. One every 3 hours. 
Constipation should be relieved every 2 days by 
enemata of water containing a small amount of 
soapsuds. 
Hemorrhage.-Elevate the foot of the bed; 
allow the stools to be passed into the draw-sheet; 
apply an ice-bag or ice-coil to the abdomen; and 
give a hypodermic injection of morphin (1/4 
grain), though it has the disadvantage of masking 
the symptoms. Administer internally opium 
(1 grain) every 3 hours, or the lead and opium pill. 
The diet should be very bland, consisting of pep- 
tonized milk, or malted milk. 
Peritonitis without perforation may have a 
favorable outcome if absolute rest be insisted upon. 
Morphin (1/4 grain hypodermically) should be 
given, and repeated if necessary. 
Perforation and peritonitis, as a rule, end 
fatally. Laparotomy should be done as soon as 
the diagnosis is positive; of about 120 cases col- 
lected by Finney, 20 percent recovered. G. E. 
Armstrong well says: Local anesthesia has very 
materially altered our attitude towards early 
operations. It is no longer necessary to administer 
a gener alanesthetic. The abdomen can be quite 
well opened under local anesthesia without causing 
the patient any pain whatever. A 1 percent solu- 
tion of novocain, with the addition of two drops of 
adrenalin, 2 min. to 1 dr., is thoroughly satisfactory 
and may be used freely. First inject the skin and 
subcutaneous tissue, and then with a needle 1 in. 
long, penetrate the deeper muscular layers along 
the line of incision. Either a gridiron incision or 
one along the outer border of the right rectus 
answers admirably But early operation is 
most essential if success is to be obtained." 
Heart-failure.-When the pulse grows succes- 
sively weaker, whisky (3 ounces) should be allowed 
every 3 hours, day and night, if necessary. 
I). Turpentine, 
Compound tincture 
of lavender, 
Sugar, 
each, 3 jss 
Acacia, 3 ij 
Water, enough to make 3 iij. 
Two teaspoonfuls every 3 or 4 hours. 
1$. Beta-naphthol, 3 ss 
Bismuth subnitrate, 3 j. 
Divide into 6 powders. One powder 
every 3 or 4 hours. 
The following may also be tried: 
3. Guaiacol, 
Salol, 
each, gr. v 
Beechwood creosote, nt v. TYPHOID FEVER 
TYPHUS FEVER 
I). Aromatic spirit of ammonia, 3 iv 
Tincture of digitalis, 3 ij 
Elixir curacoa, 3 iij 
Water, enough to make g iij. 
Two teaspoonfuls in water every 3 hours. 
Strychnin (1/40 grain) or ether (30 minims) 
may be given hypodermically. From 1/2 to 1 
liter of salt solution may be infused beneath the 
skin 3 or 4 times a day. Collapse may be treated 
by camphor (1 grain) in olive oil, (15 minims) given 
hypodermically. 
Nervous symptoms are best treated by hydro- 
therapy. In the cases that show meningeal symp- 
toms the cold pack should be used. An ice-cap 
may be applied to the forehead and one to the 
back of the neck. Blisters are of doubtful benefit, 
and add to the distress. For insomnia sulphonal 
(15 grains) or chloralamid (30 grains) or trional 
(10 to 15 grains) may answer. As a last resort 
give chloral or morphin (1/4 grain) hypodermic- 
ally twice daily. 
Sore Mouth.-Cleanliness of the mouth in the 
treatment of typhoid fever becomes of the great- 
est importance. One of the chiefest aims should 
be to keep the appetite and digestion in the best 
condition possible. Remedies given for other 
conditions arising during the course of the fever 
are seldom received with more gratefulness than 
those used for this purpose. If the teeth, tongue, 
and gums of the patient are sponged daily with a 
very weak (0.5 percent) carbolized glycerin solu- 
tion, many cases of diarrhea and tympanites will 
be prevented. Sordes accumulate upon the teeth, 
the appetite is lost, the lips become parched, the 
thirst is unquenchable, and a condition of much 
discomfort supervenes when cleanliness is neg- 
lected. It should be remembered that in this 
disease mouth-breathing is common, causing the 
tongue to become dry and brownish; and, if it is 
neglected, it may become fissured. 
I). Phenol, gr. v 
Glycerin, 5 iij 
Peppermint water, g j 
Water, enough to make g iv. 
To be used with tooth-brush at least once daily. 
TYPHUS FEVER.-An acute, infectious, and 
epidemic fever, highly contagious, and character- 
ized by sudden invasion, profound depression of 
the vital powers, sickening odor, and a peculiar 
maculated and petechial eruption, favorable cases 
terminating by crisis about the fourteenth day. 
There is no constant lesion. 
Etiology.-It is due to a special organism, the 
Bacillus typhi exanthematici, recently (1915) iso- 
lated by Plotz. The organism is gram-positive, 
from 1 to 2 mikrons in length, the breadth being 
about one fourth of the length. It has no capsule, 
and is not acid fast. It is probably carried by bed- 
bugs and body lice. It is rarely seen in the 
United States except in seaports. The period of 
incubation is about 12 days. 
Symptoms.-It begins abruptly with a chill, 
followed by violent fever, the temperature within 
a few days reaching 104° to 105° F. There is a 
frequent, bounding pulse, soon becoming small, 
weak, and rapid. The cardiac impulse and first 
sound are almost effaced, there is severe headache, 
followed by violent delirium. From the fifth to 
the seventh day a coarse, red, diffused, measly 
eruption, with a mottling of the skin, develops all 
over the body except the face, not disappearing 
on pressure. The face is apathetic and has a uni- 
form deep, dusky flush, the skin has a glazed 
appearance, the pupils are contracted, and the 
conjunctiva is red and congested. With the 
development of the disease there is cutaneous 
hyperesthesia, muscular soreness, and tenderness 
over the tibia. There are great prostration and 
muscular feebleness, vertigo, tremor, and subsul- 
tus. Constipation is the rule. At the end of the 
second week the temperature suddenly declines 
and the patient passes into a rapid convalescence. 
Complications.-Pneumonia and swollen parotid 
glands are common. 
Diagnosis.-It is differentiated from typhoid 
fever by the age, season of the year, onset of the 
1$. Strontium bromid, 
Sodium bromid, 
each, 5 vj 
Peppermint water, enough to 
make 3 iij. 
A tablespoonful every 3 hours. 
1$. Extract of opium, gr. iij 
Asafetida, 3 ss 
Extract of henbane, gr. iij. 
Add enough cacao-butter to make 6 supposi- 
tories. One to be used every 4 hours. 
I). Chloral, gr. xv 
Strontium bromid, 3 jss 
Water, g vj. 
Use as enema with a long rectal tube, in- 
serted about 18 inches. 
Diuretic solutions: 
I|. Sweet spirit of niter, g ss 
Solution of potassium citrate, g ijss 
Elixir curacoa, 3 iij 
Water, enough to make g iv. 
A tablespoonful every 3 hours. Large quan- 
tities of water may be given immediately 
after each dose of medicine.) 
Also- 
3. Potassium acetate, 
Tincture of digitalis, 
Elixir curacoa, 3 ijss 
Water, enough to make 3 iv. 
A tablespoonful every 3 or 4 hours. 
each, 5 jss 
Suppression and Retention of Urine.-Suppres- 
sion of urine is a rare complication. Retention, 
however, frequently occurs, and may be relieved 
with a sterilized catheter 2 or 3 times daily. 
Bed-sores.-Prevent bed-sores by hydrotherapy 
and by sponging the back frequently with diluted 
alcohol. Should they form, treat them antiseptic- 
ally. TYPHUS FEVER 
disease, character of the eruption, intestinal symp- 
toms, and the Widal reaction. The following is 
a comparative table, showing the main points in 
differential diagnosis. 
TYROTOXICON 
Measles begins milder, with coryza and cough, 
and never shows such pronounced nervous phenom- 
ena; but an early eruption occurs, appearing on 
the face. 
Cerebrospinal fever has many symptoms in com- 
mon, and but for the rarity of typhus in this coun- 
try would be more confusing. The headache and 
rigidity of the muscles of the neck are much more 
pronounced in cerebrospinal fever and the prostra- 
tion is less than in typhus fever. The eruption of 
typhus is characteristic, and should prevent error. 
Specific microorganisms are found in cerebrospinal 
fever. 
In the early stages small-pox and bubonic plague 
have been mistaken for typhus fever. 
Prognosis.-The unfavorable indications are 
high temperature, frequent pulse, early stupor, 
presentiment of death. The favorable indications 
are youth, moderate temperature and pulse, and 
mild nervous phenomena. 
The duration is about two weeks. The mortality 
varies from 10 to 30 percent. 
Treatment is symptomatic. As typhus fever 
is distinctly contagious, isolation is imperative, 
with immediate removal and disinfection of 
the patient's excreta. Body lice and bed-bugs 
(the carriers of the disease) are best destroyed by 
steam. All cases are benefited by small doses of 
the mineral acids, alternating with quinin sulphate. 
For high temperature, cold sponging, cold pack, 
or full doses of quinin, antipyrin, acetanilid, 
or acetphenetidin, or the systematic use of the 
cold bath, or "tubbing," as now used in typhoid 
fever. 
For the headache and delirium, cold to the head 
is indicated. In the young and strong a few leeches 
to the temple, and chloral, with or without the 
bromids, may be used. For constipation mild laxa- 
tives are given. For the debility give alcohol early 
and in full doses, and spirit of chloroform in dram 
doses whenever there is danger of collapse. During 
convalescence such tonics as quinin and strychnin 
may be given. The patient may be nourished 
by nutritious liquids, such as milk, broths, egg- 
nog. etc. 
TYROTOXICON.-A ptomain obtained by 
Vaughan from poisonous cheese, poisonous milk, 
poisonous ice-cream, etc. Chemically, it is very 
unstable; it may disappear altogether in 24 hours 
from milk rich with the poison. It induces vertigo, 
nausea, vomiting, chills, rigors, severe pains in the 
epigastric region, dilatation of the pupils, griping 
and purging, a sensation of numbness, or " pins and 
needles," especially in the limbs, and marked pros- 
tration or death. The symptoms may vary 
somewhat in different individuals. The poison is 
thought to be the cause of the summer diarrhea of 
infants. 
Treatment of Poisoning.-It is best to give 
emetics if vomiting is not free, or to employ the 
stomach-pump or siphon to wash out the stomach, 
and to administer thymol in alcoholic solution, or 
salol, napthalin, or other antiseptics. The an- 
tagonists are opium and other sedatives. Stimu- 
lation is necessary when there is prostration. See 
Ptomain-poisoning. 
Typhus Fever. 
Attacks quickly; incuba- 
tion 9 days. 
Occurs at any age. 
Rare among the higher 
classes, except those 
exposed. 
Mulberry eruption on 
fourth or fifth day, on 
extremities, lasts until 
close. 
Brain chiefly affected; 
bowels often but little 
so; abdomen natural; 
evacuations dark, but 
never bloody (these 
are ocasionally r e - 
versed). 
Contracted pupils; dus- 
ky face. 
Pulse increases to 120, 
and temperature rises 
to 105°F., until third 
day; high for 6 days, 
then fall. 
Lasts from 2 to 3 weeks. 
Relapses rare. 
Death from coma or 
from congestion of the 
lungs in first or second 
week. 
Arises from destitution, 
overcrow ding, bad 
ventilation; is highly 
contagious and gener- 
ally epidemic; no 
microbe determined. 
Postmortem: changes 
not constant; the most 
frequent are dark 
blood,enlarged spleen, 
soft heart. 
Typhoid Fever. 
Commences slowly; 
incubation about 13 
days. 
Most common in youth 
and childhood; rarely 
occurs after 40. 
As common among the 
rich as among the 
poor. 
Rose eruption on 
seventh to tenth day; 
isolated, flattened 
papules (few) on ab- 
domen and back, 
in successive crops, 
which fade and disap- 
pear. 
Bowels chiefly affected; 
evacuations ocher 
color and watery; 
sometimes hemor- 
rhage or even ulcera- 
tion; abdomen tumid. 
Dilated pupils; cheeks 
flushed. 
Pulse and tempera- 
ture rise and fall in- 
dependently, and 
without uniformity, 
but both are usually 
high to fifteenth day. 
Lasts from 4 to 6 weeks 
or longer. 
Relapses frequent. 
Death from asthenia, 
pneumonia, h e m o r- 
rhage, or perforation of 
intestine, in or after 
third week. 
From poisoned drinking- 
water, putrid animal 
matter, bad drainage; 
is not contagious, of- 
ten sporadic; Eberth's 
bacillus present in 
the intestinal lesions, 
and in the spleen, 
liver, blood, etc. 
Postmortem: morbid 
Peyer's patches; en- 
larged mesenteric 
glands; ulcerated 
mucous coat of intes- 
tines; enlarged and 
soft spleen; ulcerated 
pharynx. 
Responds to the Widal 
reaction. ULCERS 
ULCERS 
u 
ULCERS.-An ulcer is the term applied to an 
open sore produced by a loss of substance of the 
free surface of the skin or mucous membrane in the 
process of ulceration, or of ulceration and gangrene 
combined. The term, moreover, is sometimes 
extended to any open granulating wound the 
result of an injury or operation. 
Varieties.-The various names given to ulcers 
are derived either from their local conditions and 
surroundings or from their specific cause. The 
characters of the specific ulcers, however, often 
become obscured by accidental local conditions; 
and these latter, again, are constantly changing 
from day to day, so that an ulcer which at one 
time would be called callous, may at another 
time be in a sloughing state. The following are 
examples of the chief types of ulcers, but in 
practice many minor shades of difference in the 
local appearances occur, so that it may be difficult 
or impossible to assign a given ulcer to a particular 
type. 
The Simple, Healthy, or Healing Ulcer.-The 
edges are smooth and shelving, and extend in the 
form of a bluish-white film over the marginal 
granulations. The base is level, or nearly so, 
and is covered with healthy granulations. The 
discharge is inodorous pus, or if the ulcer is dressed 
antisepically, and all irritation avoided, merely 
healthy serum. The surrounding skin is healthy. 
This is the type that all ulcers assume when 
healing. 
Treatment.-Rest and protection by any light 
unirritating dressing are all that is usually re- 
quired. When large, cicatrization may be pro- 
moted by skin-grafting. Two methods are em- 
ployed. See Plastic Surgery. 
The exuberant or fungous ulcer is generally due 
to obstructed venous return from the granula- 
tions, the result of undue contraction of surround- 
ing tissues, as seen for example, after a burn. 
The edges are healthy, but the granulations rise 
above the surface, and are turgid, dark red, re- 
dundant, and bleed readily. The discharge is 
purulent. 
Treatment.-Solid nitrate of silver or sulphate of 
copper should be rubbed over the granulations 
until they are reduced to healthy proportions. 
The edematous or weak ulcer generally occurs 
in connection with tubercular bones or joints, but 
any ulcer may become edematous if healing is 
delayed by the prolonged use of emollient ap- 
plications. The edges and adjacent tissues are 
generally healthy; and the granulations are 
upraised, flabby, bulbous, semitranslucent, watery, 
and friable. The discharge is profuse and watery. 
Treatment.-Removal of the cause, when 
possible, uniform pressure, and applications of 
lotions of nitrate of silver or similar astringents. 
The Inflammatory and Inflamed Ulcers.-These 
terms are applied to ulcers in which the in- 
flammatory phenomena are the most marked 
features. The inflammation may depend on 
some constitutional disturbance consequent upon 
alcoholism, improper food, and the like; or it 
may be the result of local irritation applied 
to any ulcer, whatever its previous charac- 
ter. For the purpose of distinction, the term 
"inflammatory" is applied to the former con- 
dition, while the term "inflamed" is generally 
restricted to ulcers of the latter class. Inflam- 
matory ulcers are usually of irregular shape: 
the edges are ragged and shreddy, or abrupt or 
sharp-cut; the surrounding skin is red and ede- 
matous, and the base void of granulations, dry, 
livid red, or covered with a serous or sanious dis- 
charge mixed with tissue debris, and, if the in- 
flammation is very acute, with yellow sloughs. 
When inflammation attacks a previously granu- 
lating ulcer, the granulations become florid and 
swollen, and generally slough, while the surround- 
ing parts present the ordinary inflammatory 
phenomena. 
The treatment should consist of rest, elevation 
of the part, removal of all local irritation, applica- 
tion of warm antiseptic lotions (as boric acid) 
on lint, attention to the constitutional state, and 
regulation of the secretions. 
The Sloughing Ulcer.-This is merely a severer 
degree of the former, and it differs from it in that 
the inflammatory process is more intense and of a 
spreading character. It seldom occurs except in 
connection with venereal disease. The micro- 
organisms at work in this and in the phagedenic 
form of ulcer are probably only the ordinary 
pyogenic micrococci found in all ulcers, but here 
acting with greater intensity in a vitiated con- 
stitution. The ulcer spreads with great rapidity, 
the edges are undermined, inverted, and dusky 
red, and the base is covered by an ash-gray or 
black slough. There are, commonly, much 
pain and severe constitutional fever. 
The treatment is similar to that of the inflamed 
variety. Antiseptics should be freely used if the 
ulcer is foul, and opium should be given if there 
is much pain. When due to syphilis, the proper 
remedies for that affection should, of course, be 
given; but mercury should be used cautiously 
or should be altogether withheld until the slough- 
ing has ceased. 
The phagedenic ulcer, owing to improved sanita- 
tion and hygiene, and to the more scientific treat- 
ment of wounds, is seldom seen at the present day- 
except in connection with venereal disease in 
persons whose constitution is thoroughly broken 
down by intemperance, defective nutrition, and 
general neglect. The edges of the ulcer are ir- 
regular, swollen, and undermined, and the sur- 
rounding skin is of a dark, purplish, and dusky ULCERS 
UMBILICAL CORD 
red color. The surface is devoid of granulations, 
and is covered with a dark, blood-stained, ichorous 
discharge, often mixed with sloughs. When the 
sloughing proceeds to any extent, the ulceration 
is spoken of as sloughing phagedena. The ulcer 
spreads with fearful rapidity, and often destroys 
the whole organ, as the penis or vulva, and is 
attended with severe constitutional disturbance. 
Treatment.-The patient should be placed under 
an anesthetic, the surface of the ulcer dried, and 
then thoroughly destroyed with fuming nitric 
acid. Some surgeons apply carbolic acid (1:20) 
or perchlorid of mercury (1:1000), and then dust 
with iodoform. Application of pure bromin is 
very effective. The continuous use of the hot bath 
is often of much service in phagedena of the penis 
and vulva. Internally, opium should be given in 
full doses, with tonics, nourishing diet, and, when 
indicated, stimulants. Thorough ventilation and 
good hygiene generally are imperative. 
The Chronic, Callous, or Indolent Ulcer.-This 
condition of an ulcer is the result of continued 
irritation and neglect, in consequence of which 
the edges become infiltrated with inflammatory 
material, which impedes the circulation and 
prevents healing. It is very common in the 
lower third of the leg in the poorer classes. The 
edges are smooth, white, callous, rounded, steep, 
and quite insensitive when touched. The adja- 
cent skin is generally congested or eczematous. 
The base is covered with a thin, sanious discharge, 
while there are either no granulations, or those 
present are small, flabby, pale, and ill formed. 
These ulcers often exist for years, and are usually 
attended with but little pain, and though they are 
at times small, at other times they extend nearly 
round the leg. They are often adherent to the 
fascia, periosteum, or bone. Old, callous ulcers, 
when subjected to continued irritation, are apt, 
as age advances, to become epitheliomatous. 
Treatment.-The callous edges should first be 
softened by emollient dressings, and uniform 
pressure subsequently applied by a Martin's 
bandage or by strapping and a bandage. The 
strapping plaster, cut into strips 11/2 inches wide, 
should be evenly applied and should extend 2 
inches below and the same distance above the 
ulcer. Holes should be cut in the strapping 
opposite the ulcer to allow of the escape of the 
discharge. Over the strapping a bandage from 
the foot to the knee should be applied. The 
bandage should be changed daily; the strapping 
once or twice a week. Iodoform or some other 
antiseptic powder should be sprinkled on the ulcer 
beneath the strapping. Other applications which 
have been found useful are Unna's paste, spirit of 
camphor, tincture of iodin and a weak solution of 
sulphate of copper, two or three grains to the 
ounce. 
Cases intractable to other treatment have been 
much benefited and sometimes cured by baking in 
the hot air oven for thirty minutes daily. 
When these ulcers are adherent to the fascia or 
periosteum their base should be liberated either 
by multiple radiating incisions or by a circular 
incision about a half an inch from their edge. 
When the ulcer is very large or extends quite 
round the leg or shows signs of becoming epithelio- 
matous, amputation is indicated. 
The Varicose and Eczematous Ulcer.-These 
terms are applied to any ulcer, whatever its other 
characters, when associated respectively with a 
varicose state of the veins or an eczematous con- 
dition of the skin. Both conditions frequently 
occur together. 
The Irritable or Painful Ulcer.-Though any 
ulcer may be irritable or painful, these terms are 
generally restricted to a small, painful ulcer around 
the anus, and to a small, superficial, generally 
congested ulcer, commonly situated near the ankle, 
and occurring chiefly in women beyond middle 
life. The pain is often intense, and is generally 
believed to depend upon the involvement of the 
nerve-endings. 
Treatment.-The improvement of the general 
health, small doses of opium, and cauterization 
with nitrate of silver, will often suffice to cure the 
ulcer. In inveterate cases an attempt may be 
made to divide the nerves subcutaneously, after 
the manner of Hilton. 
Tuberculous or strumous ulcers are generally due 
to the breaking down of enlarged tuberculous lym- 
phatic glands, the bursting of subcutaneous tuber- 
culous abscesses, or the ulceration of the so-called 
tuberculous or strumous nodules. They are gener- 
ally multiple, and often confluent, forming an irreg- 
ular indolent sore. The edges are pale, bluish-pink, 
thin, and undermined. The granulations are pale, 
edematous, protruding, and bleed readily on hand- 
ling. The discharge is thin, yellowish-green, and 
scanty. Enlarged glands and ci.catrices of former 
ulcers are frequently present in their vicinity. 
The cicatrices are generally raised, pale pink or 
white, while the skin is often puckered around them. 
Treatment, constitutionally, is that for struma 
and tubercle. Locally, the sore should be de- 
stroyed by paring away the edges and scraping the 
base with a Volkmann's spoon. The cicatrices 
may sometimes be dispersed by repeated blister- 
ings or by subcutaneous division. 
Syphilitic Ulcers.-Primary ulcers or chancres 
are described under Syphilis (q. v.). Those 
occurring in the course of constitutional syphilis 
may be divided into the superficial and deep, and 
are treated locally as well as constitutionally. 
ULNA.-See Forearm. 
UMBILICAL CORD (Funis).-A vascular, cord- 
like structure connecting the fetus with the 
placenta. 
Origin.-It is derived from the pedicle of the 
allantois, appearing about the third week of ges- 
tation. When fully formed, it is composed of two 
arteries, one vein, the omphalic duct, the remains 
of the umbilical vesicle, and the pedicle of the 
allantois, surrounded by a covering of mucous 
tissue (Wharton's jelly), and insheathed by a 
layer of amnion. At term the cord is from 50 to 
60 cm. in length, and from 1 to 2 cm. in thickness. 
Function.-It is the medium of communication 
between the mother and child. It supplies the 
fetus with rich arterial blood, and returns to the 
mother impure venous blood. UMBILICAL CORD 
UNGUENTUM 
Abnormalities. Length.-The cord may be 
very much longer (250 cm.) or very much shorter 
(1 cm.) than normal. If too long, it is likely to 
be coiled about the fetus or is liable to prolapse; 
if too short, it may prevent descent of the fetus, 
causing great pain at the placental site and, finally, 
premature detachment of the placenta. 
Thickness.-Sometimes there may be an excess 
of mucous tissue, causing great increase in the 
thickness of the cord. This does not usually 
involve its entire length. 
Torsion.-From 8 to 12 twists in the cord are 
normal; they are caused by the twisting of the 
arteries around the vein. Extreme torsion may 
sometimes occur, rarely causing interference with 
the blood supply to the fetus. 
Coils and Knots.-True knots have been found 
in the cord, although they are not usually tight 
enough to interfere with the circulation. The 
cord is frequently found coiled around the child's 
body. In about 25 percent of cases it is coiled 
around the neck. 
Insertion.-The cord is usually inserted into 
the central part of the placenta, occasionally into 
the periphery (battledore placenta). When the 
vessels run between the amnion and chorion 
before entering the placenta, it is said to be a 
velamentous insertion. 
Cysts, Tumors, and Calcareous Deposits.-These 
conditions are occasionally found in the cord, but 
they are, as a rule, of no significance. 
Care after Labor.-After the pulsations in the 
cord cease it should be ligated, a piece of narrow 
iodoform tape or aseptic silk being used for this 
purpose. Only one ligature should be used, 
placed about 11/2 inches from the child's abdo- 
men. It should first be secured by an ordinary 
surgeon's knot and then by a bow-knot, the ends 
being left long, so that it may be tightened after 
the child has had its bath. The cord should now 
be cut about 1/2 of an inch beyond the ligature, 
care being taken that no part of the child is in- 
jured by the scissors. The free end of the cord is 
allowed to drain into a vessel, thus decreasing the 
size of the placenta, facilitating its separation 
from the uterus, and hastening its expulsion. 
After the child has received its bath, the ligature 
around the cord should be tightened, and the cord 
dusted with a powder composed of salicylic acid 
and powdered starch, 1 part to 4 respectively. 
It should now be inclosed in a piece of salicylated 
cotton and the binder applied. The cord usually 
drops off about the fourth day; the granulating 
ulcer remaining gradually heals and retracts, 
forming the umbilicus. 
Septic Infection.-This is a rare condition if 
proper asepsis is observed in ligating and dressing 
the cord. When present, the cord is inflamed and 
thickened, and a grayish, diphtheritic membrane 
may cover its distal end. High fever is a usual 
accompaniment. 
The treatment consists of applications of a 
strong solution of mercuric chlorid (1 : 500) and 
in proper dressing, as described. 
Umbilical Fungus.-An overgrowth of granu- 
lations may occur about the umbilical ulcer or the 
cord may remain as a projection of well-organized 
connective tissue. In the former case the granu- 
lations should be cauterized with nitrate of silver; 
in the latter the cord should be religated close to 
the abdominal wall and the excess removed with 
scissors. 
Hemorrhage (Omphalorrhagia).-This may be 
primary, from imperfect ligation of the cord, or 
secondary, occurring after the cord has fallen. 
The mortality is very high, being probably 
75 percent or more. 
Treatment.-In primary hemorrhage the cord 
must be religated; occurring from the umbilical 
ulcer, after the cord has fallen, the bleeding 
point, if seen, should be ligated, or pressure and 
astrigents may be tried. If these fail, a fold of the 
abdominal wall should be transfixed with a hare- 
lip pin passing below the umbilicus, the pin passing 
beneath the hypogastric arteries; over this a figure- 
of-eight ligature should be applied. Occasionally, 
it may be necessary to pass a second pin above 
the umbilicus, so as to occlude the umbilical 
vein. 
Prolapse.-The descent of a loop of cord in 
advance of the presenting part of the fetus. This 
is not a very rare complication, occurring once 
in about 250 labors. 
Causes.-The principal causes are: (1) Lack 
of conformity between the presenting part of the 
child and the maternal pelvis, as in deformed 
pelves, small head, and abnormal positions; (2) 
hydramnios; (3) excessive length of cord; (4) 
placenta prsevia. 
Prognosis.-The fetal mortality is high, over 
50 percent of children losing their lives from 
asphyxia. 
The treatment consists of prompt replacement of 
the cord, if possible. This may be accomplished 
by the fingers alone or by the aid of some instru- 
ment, such as a catheter and string. A piece of 
string about 4 inches long is passed through the 
eyelet of the catheter, and the ends are tied; 
the cord is placed in the angle made by the loop 
and catheter, and the free end of the loop is hooked 
over the top of the catheter. In this way the 
cord is held fast, and may be carried back into the 
uterus. When the catheter is withdrawn, the 
loop passes over the end and the cord is released. 
If the patient is placed in the knee-chest posture, 
reduction will be very much facilitated. 
After reduction has been accomplished, the 
patient should be kept in the knee-chest posture, 
or, at least, should have the buttocks elevated, 
so that the prolapse may not recur. This pre- 
caution is unnecessary after the presenting part 
has descended to the pelvic floor. 
If it is found impossible to reduce the cord, it 
should be placed in a position in which it will be 
least liable to suffer severe compression-usually 
over the left sacroiliac joint-and rapid delivery 
of the child should be effected, either with forceps 
or by version. 
UNCINARIASIS.-See Ankylostoma, Hook- 
worm Disease. 
UNCONSCIOUSNESS.-See Coma. 
UNGUENTUM.-See Ointment. URANOPLASTY 
URETERS, CATHETERIZATION 
URANOPLASTY.-See Cleft Palate. 
URATES.-Combinations of uric or lithic acid 
with a base. See Urine (Examination). 
UREA.-CO(NH2)2. The chief solid constitu- 
ent of urine and the principal nitrogenous end- 
product of tissue metamorphosis. See Urine 
(Examination). 
UREA-QUININ.-See Quinin and Urea Hy- 
DROCHLORID. 
UREMIA.-The name given to a certain group 
of symptoms resulting from nephritis, and due 
to the circulation in the system of the effete 
products that should be eliminated by the kidneys. 
Etiology.-The exciting agent is unknown. 
Certain facts, however, lead to the belief that there 
is an accumulation in the system of organic basic 
products-ptomains and leukomains-which may 
cause uremia. 
Symptoms and Clinical Course.-These are 
mainly referable to the nervous system. In acute 
uremia the symptoms may appear without any 
previous warning. In the more chronic form there 
are such premonitory symptoms as headache, 
vertigo, morning nausea, indistinct vision, drowsi- 
ness, cool skin, obstinate constipation, various 
cutaneous eruptions, and a diminution in the 
amount of the urine, which usually contains albu- 
min and casts. 
The uremic attack may manifest itself in a 
variety of ways: 
Gastrointestinal Variety.-The patient suddenly 
experiences attacks of vertigo, pallor of face, 
nausea and vomiting, with fever, the temperature 
varying between 100° and 103° F., pulse tense and 
rapid, respiration hurried, and the urine scanty, 
with low specific gravity; unless the symptoms are 
promptly relieved, convulsions may occur, followed 
by coma and death, or drowsiness may supervene, 
followed by coma, which is really nothing but a pro- 
found sleep. Rarely, an acute maniacal outbreak 
follows the gastrointestinal symptoms. 
Convulsive Variety.-Without any appreciable 
prodromes there are epileptiform convulsions, with 
or without loss of consciousness. The convulsions 
may consist of a single paroxysm, or a succession 
of fits may follow one another at intervals of a few 
minutes or of several hours, the patient being in a 
condition of more or less profound insensibility 
during the intervals. The fits almost exactly 
simulate true epilepsy. In this variety the tem- 
perature is high-from 103° to 106° F., or more; 
the pulse is rapid, with or without tension; the 
respirations are quickened. Coma, followed by 
death, is a very common ending of this variety 
of uremia, or after a profound sleep of hours the 
patient gradually recovers his usual health. Alco- 
holic excesses are responsible for many of these 
attacks. 
Cerebral Variety, or Uremic Coma.-This form 
develops either gradually, with an increasing 
drowsiness, associated with headache and irri- 
tability of temper (mild mania), nausea, vomiting, 
and rise of temperature, often reaching 105° F., 
rarely 107° F., with rapid, full pulse; or the patient 
may fall suddenly into a condition of profound 
coma, the symptoms closely resembling an apo- 
plectic stroke, except the high temperature. 
Uremic coma is always accompanied by rise of 
temperature and stertor. This stertor is peculiar; 
it is not the "snoring" of apoplexy, but a sharp, 
hissing sound produced by the rush of expired air 
against the teeth or hard palate. The respirations 
are acclerated and the pulse is rapid, but of low 
tension. This variety may suddenly terminate 
fatally with a convulsion, or a deepening coma with 
prostration and cold, wet skin, with edema of the 
lungs. Rarely, there may be gradual recovery. 
Pulmonary manifestations are nocturnal dysp- 
nea, usually of a paroxysmal character. Cheyne- 
Stokes breathing may continue for several weeks, 
and is not a necessarily fatal symptom. 
Abdominal manifestations are obstinate vomiting 
and profuse diarrhea. 
General Manifestations.-The skin is dry and 
has a dusky hue; the breath has a urinous odor; 
the urine is scanty, albuminous, contains different 
varieties of casts, and is deficient in urea. The 
temperature is normal or slightly subnormal, and 
the pulse is slow and full, until late in its course, 
when it becomes rapid and feeble. 
Differential Diagnosis.-The clinical history and 
examination of the urine wall aid in determining the 
diagnosis. See Coma, Convulsions. 
Prognosis is unfavorable. 
Treatment.-The first indication is to aid the 
disabled kidneys in eliminating the waste products 
of the body by stimulating the skin and bowels to 
activity. Croton oil (1 or 2 drops) with olive oil 
(1 dram) should be given at once, to produce rapid 
catharsis. Elaterium (1/8 grain) may be given 
every 3 or 4 hours until 2 or 3 doses have been 
taken. Calomel (2 grains) with compound jalap 
powder (20 grains) every hour until 4 doses have 
been taken. 
A hot bath (110° F.) or a hot vapor bath should 
be given from the onset of the symptoms to pro- 
duce free diaphoresis. 
The patient may be wrapped in blankets wrung 
out in hot water and given hot drinks to increase 
perspiration. If the pulse is full and bounding, 
venesection may be performed. Chloral (1 dram) 
may be given by the rectum to control the convul- 
sions. Inhalations of chloroform or nitrite of 
amyl may also be used. 
If the pulse is feeble, the following may be used: 
I|. Tincture of digitalis, 3 ij 
Aromatic spirit of ammonia, 3 v 
Aromatic elixir, 3 iv 
Water, enough to make 3 iij. 
Two tablespoonfuls every 3 or 4 hours. 
If collapse threatens, give strychnin (1/30 grain), 
atropin (1/100 grain), or nitroglycerin (1/100 
grain) hypodermically. The diet should be com- 
posed of liquids. See Eclampsia. 
URETERS, CATHETERIZATION.-This method 
constitutes a real advance in the accurate diagnosis 
of certain morbid renal conditions. By introduc- 
ing a catheter directly into the ureter it can be 
learned whether blood or pus which is contained 
in the urine comes from the kidneys, and if so 
whether it is derived from one or both of these URETERS, CATHETERIZATION 
URETHRA (FEMALE), DISEASES 
organs. The patency of the ureter can also be 
determined, and by injecting fluid through the 
catheter it can be learned whether the pelvis of the 
kidney is dilated. Suppurative conditions of the 
renal pelvis may be treated directly by the injec- 
tion of medicated solutions. The secretory power 
of the two kidneys can also be determined when 
this method is employed in connection with certain 
functional tests. Casper and Richter found that 
in health the urine secreted simultaneously by the 
two kidneys contained about the same quantity of 
nitrogen, urea, and salts and that the freezing- 
point of both fluids was the same. In disease, 
however, these relations are altered, the diseased 
kidney excreting less than the healthy one. The 
same holds true of the excretion of phloridzin, 
which produces an artificial diabetes of short 
duration. Thus it is seen that the possibility of 
securing urine from each kidney separately by 
means of the ureteral catheter enables the clinician 
to obtain valuable diagnostic data concerning the 
functional capacity of each organ. At present it 
may be considered an invariable rule in renal sur- 
gery to have an examination of the urine obtained 
separately from each kidney made upon one or 
more occasions before resorting to operation. If 
the functional capacity of both kidneys is low, the 
removal of one might be followed by uremia and 
death. 
mucosa. When they are located the ureteral 
catheter is made to enter one orifice and passed 
upward by a slow rotary movement for a distance 
of about 5 centimeters. The same procedure is 
then repeated on the other side. 
The cystoscope may be left in situ while the 
urine is being collected, or it may be withdrawn, 
leaving only the catheters in place. With the 
improved modern cystoscopes the latter procedure 
is easy and is less disturbing to the patient. 
The urine is collected in sterile glass tubes, every 
precaution being taken to prevent contamination. 
URETHANE.-Ethyl carbamate, C3H7NO2, 
is an ester of carbamic acid, obtained by the 
reaction of ethyl alcohol upon carbamid (urea) or 
one of its salts. It occurs in colorless crystals, 
readily soluble in water, alcohol, ether, or glycerin. 
Dose, 10'to 30 grains; but is best given in doses of 
5 grains frequently repeated, up to 20 grains or 
more, as a full dose may cause vomiting. It is 
incompatible with many substances, and is best 
administered by itself. Urethane is a mild 
hypnotic for adults, but a safe and efficient one for 
children. It stimulates the respiration, and in 
medicinal doses does not affect the circulation; 
but in very large quantities it slows the heart, 
depresses the body temperature, and induces 
muscular relaxation and some degree of general 
anesthesia. 
Kelly's Searcher, above, for Investigating a Doubtful Ureteral Orifice. 
Short Ureteral Catheter, Below, with Rubber Tubing Attached. 
Catheterizing cystoscopes are made both in the 
direct and indirect varieties. The instruments of 
Nitze, Casper, Albarran, Bransford Lewis, Brown, 
and Buerger are most commonly used. They all 
carry two catheters, which permit simultaneous 
catheterization of both ureters. 
In the female the ureters may be catheterized 
by the aid of a speculum passed through a dilated 
urethra, the patient being in the lithotomy posi- 
tion with the pelvis well raised, or in the genu- 
pectoral position. The modern perfected cysto- 
scopes, however, render such a procedure unneces- 
sary, and moreover, afford an easier method for 
the average operator. 
The technic of ureteral catheterization is the 
same as that of cystoscopy. The bladder is 
washed out with sterile water or a weak antiseptic 
solution, then distended with the same fluid and 
the cystoscope introduced. The ureteral orifices 
are situated at the base of the trigone, one at either 
angle and appear as small slits in the vesical 
URETHRA (FEMALE), DISEASES. Inflamma- 
tion.-Inflammation of the female urethra is almost 
invariably due to gonorrhea. It may occasionally 
be due to traumatism, chemic irritants, drugs, 
and the exanthematous diseases. 
Symptoms.-In acute urethritis there is frequent 
and painful urination. In severe cases blood may 
appear in the urine. The external meatus is 
inflamed and swollen, and pressure over the course 
of the urethra is accompanied by intense pain 
and by the discharge of a few drops of pus. 
As the disease becomes chronic the severe symp- 
toms subside; there is little or no pain. Pres- 
sure over the urethra reveals some tenderness, 
and, if the patient has not urinated recently, will 
probably cause the discharge of a drop of pus. 
Endoscopic examination will show localized areas 
of inflammation. 
The treatment in the acute stage should consist 
of rest in bed, a nonstimulating diet, diluent drinks, 
and rather free purgation. A very good plan is to URETHRA (MALE), HEMORRHAGE 
URETHRA (MALE), INJURIES 
put the patient on an exclusive milk diet. The 
external genitals should be cleansed several times 
daily with hot boric acid solution (1 dram to 1 
pint). After the first two or three days of the 
attack salol, oil of sandalwood, cubebs, or copaiba, 
in 5-grain doses, may be given 3 or 4 times daily. 
If this treatment is ineffectual, irrigation of the 
urethra with sterile water should be tried, fol- 
lowed by the injection of a solution of nitrate of 
silver, 2 grains to 1 ounce. In injecting solutions 
of any kind into the urethra it should be remem- 
bered that its capacity is not more than 10 or 15 
drops. Occasionally, the condition will persist in 
spite of this treatment. Such cases require 
applications of a stronger solution of nitrate of 
silver (10 grains to 1 ounce) directly to the affected 
areas through the endoscope. 
Caruncle.-See Caruncle (Urethral). 
Polypus.-Polypi of the urethra are mucous in 
character. They cause no symptoms except that 
of obstruction to the flow of urine. They should 
be excised 
URETHRA (MALE), HEMORRHAGE-Hemor- 
rhage from the urethra may be caused by the intro- 
duction of a bougie, by the opening of a false pas- 
sage, by the separation of a slough formed by the 
caustic bougie, or by the rupture of a blood-vessel 
during acute chordee, or it may result from internal 
inj uries. It may occur from general arterial excite- 
ment or may be associated with Hematuria (g. v.). 
Treatment.-The recumbent posture, with ap- 
plication of cold and pressure, should be tried. 
A flat piece of cork should be pressed by the patient 
against the perineum, far back, and gradually 
moved forward until it reaches the right spot, 
when the dripping of blood will cease. A solution 
of tannic acid in water may be used as an injection. 
Gallic acid may be of service. Adrenalin solution 
has proved efficient. A steel bougie, first put in 
very hot water and then introduced into the ure- 
thra, is often used to arrest this variety of hemor- 
rhage. If the hemorrhage is from the anterior 
portion of the urethra, a catheter should be inserted 
and a bandage firmly applied around the penis. 
URETHRA (MALE), INJURIES.-Rupture of the 
urethra is a serious inj ury, as it exposes the patient 
not only to the immediate danger of extravasation 
of urine, but also to the lifelong trouble of a 
traumatic stricture. It is generally caused by a 
kick on the perineum, by a fall astride a joist or 
rail, or by the displacement of a fragment of the 
pubic arch in fracture of the pelvis. The urethra 
may also give way behind an old stricture while 
the patient is straining to empty his bladder. 
State of the Parts.-The rupture usually occurs 
where the urethra passes under the pubic arch: 
i. e., either just in front of or just behind the 
triangular ligament. In the former situation 
urine and blood will be extravasated in the peri- 
neum; in the latter, about the neck of the bladder. 
As the triangular ligament, however, is generally 
torn, some urine will, as a rule, in the latter case 
also pass forward into the perineum. The urethra 
may be completely torn across, or the rupture may 
only be partial, the upper wall escaping. 
The symptoms are usually quite obvious. 
Together with the history of an accident there will 
be pain, swelling, and the ecchymosis of the peri- 
neum, and escape of blood, often in considerable 
quantities, from the urethra. The patient is 
unable to pass water, and any attempt to do so 
merely forces more urine into the tissues of the 
perineum, and gives pain. On trying to pass a 
catheter, some obstruction is generally met with, 
and will often prove insurmountable; but if the 
catheter is finally passed, clear urine will escape. 
These signs distinguish it from ruptured bladder, 
in which injury the catheter passes easily, but, 
generally (although the bladder is said to have 
been full at the time of the injury), only a little urine 
flows. In mere bruising and ecchymosis of the 
perineum the catheter will pass easily, and there 
is, as a rule, no escape of blood from the urethra. 
See Hematuria, Urine (Examination). 
Treatment.-A sbft catheter should be passed, 
if possible; if not, a gum-elastic or a silver one; and, 
in any case, the catheter should be tied in. Failing 
to pass a catheter, an extravasation of urine in 
any quantity having already occurred, a silver 
catheter should be passed down to the obstruction 
and a free incision through the middle line of 
the perineum made on its point. If the proximal 
end of the torn urethra can now be found, the 
catheter should be passed through it into the 
bladder and tied in. If not readily discovered, a 
prolonged search for it need not be made, as with 
a free incision through the perineum there is no 
danger of further extravasation of urine. If the 
urethra is found only partially torn across, an 
attempt should be made to bring the edges together 
by suture over a catheter, the external wound in 
the perineum being then united by deep sutures. 
The catheter should be kept in place for a week. 
Should a fragment of the pubic arch be found com- 
pressing the urethra, steps must be taken to re- 
move it, the bladder in the mean time being 
aspirated above the pubes to prevent further 
extravasation occurring. When the wound in the 
perineum is left to granulate in the ordinary way, 
a silver catheter-as the point of this is more under 
control than that of a soft one-should be passed 
daily during the healing of the wound, and the 
patient should be enjoined subsequently to pass 
one for himself at frequent intervals, and warned 
that if he neglects to do so, a stricture will gradu- 
ally form (Walsham).. 
Foreign bodies introduced into the urethra 
require extraction. Urethral forceps should be 
avoided as far as possible; sometimes, by placing 
the patient in a hot bath, giving him plenty of 
liquid to drink, and directing him to retain his 
water, sufficient can be withheld to drive out such 
an obstruction, for example, as the end of a cath- 
eter broken off in a stricture; but this should not 
be tried too long. Hair-pins, on the other hand, 
and such structures, nearly always require incision. 
The cases in which the obstruction is slight and 
a stone lies out of the way are much more rare, 
and, as a rule, occur only in elderly men. In a 
few instances huge cylindric calculi have been 
found, 3 or 4 inches in length and 11/2 inches in 
circumference. These generally lie in the tissue URETHRA (MALE), STRICTURE 
URETHRA (MALE), STRICTURE 
by the side of the urethra, occupying a cavity 
which they have worn out for themselves, and 
sometimes they are so invested by the mucous 
membrane that a sound may be passed down by 
them without any characteristic grating. 
URETHRA (MALE), STRICTURE.-In the male, 
stricture may be either congenital or acquired. 
Congenital stricture occurs but rarely, and is usu- 
ally confined to the meatus. Acquired stricture 
may be defined as an abnormal lessening of the 
caliber of the urethra, or of the dilatability of the 
urethral canal, associated with changes in the 
mucous, submucous, or muscular structures con- 
stituting its walls. This definition embraces the 
varieties of strictures known as inflammatory, 
spasmodic, and organic. 
Inflammatory stricture is a narrowing of the 
caliber of the urethra, due to inflammation; it is 
usually of short duration, is seldom attended with 
retention of urine, and is frequently the starting- 
point of organic stricture. 
Spasmodic Stricture.-This condition is due to 
contraction of the muscular fibers of the urethra; 
it is frequently reflex in character, as is shown by 
the retention of urine that sometimes follows 
surgical operations on the anus, rectum, penis or 
scrotum. It may be caused by shame, fear, or 
anger, or by a hyperesthetic condition of the canal. 
Organic stricture may exist in either sex. In 
the male it occurs early in life; it is most common 
between the ages of 25 and 45. It is caused by 
long-standing urethritis, by traumatism, and, 
according to some authorities, by masturbation. 
Symptoms.-As a rule, it will be found that the 
individual has suffered one or more attacks of 
urethritis within a year or two previous to present- 
ing himself for treatment. A frequent desire to 
urinate, more urgent during the day, is usually 
one of the early symptoms; the stream is much 
reduced in size, and may be forked, twisted, or 
spray-like. After the stricture has existed for some 
time and atony of the bladder has developed, there 
will be marked diminution of the expulsive force. 
Dribbling from the urethra is frequently an early 
symptom, depending on the condition of the circu- 
lar muscular fibers of the urethra. Late in the 
disease incontinence of urine sets in, which is the 
so-called "incontinence of retention;" it is more 
persistent during the day. 
When inflammation of the prostate or bladder 
exists, ardor urinse will prevail. The same causes 
may give rise to vesical tenesmus. Urethral dis- 
charge is present in about 50 percent of the cases, 
and is usually of a mucoid character; retention is, 
as a rule, a late symptom, and is caused by expo- 
sure to cold, unusual exertion, alcoholic excess, or 
immoderate coition. 
Strictures of very small caliber may markedly 
interfere with the act of coition: the stricture be- 
coming congested during the sexual embrace, 
prevents the semen from passing forward, and it 
slowly dribbles away after the erotic act has 
terminated. 
In cases of long standing in which a diseased con- 
dition of the bladder and kidneys exists, associated 
with alternation in the character of the urine, there 
will frequently be found well-marked constitu- 
tional symptoms, such as uremia and septicemia. 
Treatment.-The patient must be carefully 
examined, so as to ascertain the number, position, 
caliber, resiliency, and relative irritability of the 
strictures. The condition of the bladder and 
kidneys must be determined, and a microscopic and 
chemic examination of the urine must be made, 
to decide whether any pus, mucus, or blood is pres- 
ent, or whether any casts are to be found. If pos- 
sible, a bacteriologic study of the urine should be 
made, as the presence of pathogenic organisms has 
often a great bearing on the treatment of the case. 
The quantity of urine passed during 24 hours 
should be fixed upon and the amount of urea 
clearly ascertained, together with the aggregate of 
albumin and sugar. Having obtained these data, 
the surgeon will be enabled to decide upon the 
proper operation to be performed. 
The numerous methods resorted to for the ex- 
tirpation of urethral stricture are: (1) Gradual 
dilatation; (2) continuous dilatation; (3) modified 
rapid dilatation; (4) internal urethrotomy; (5) 
dilating internal urethrotomy; (6) dilating internal 
and external perineal urethrotomy; (7) external 
perineal urethrotomy with guide; (8) external peri- 
neal urethrotomy without guide; (9) electrolysis; 
(10) urethrectomy; (11) divulsion. 
1. Gradual Dilatation.-This is the treatment 
usually pursued for the relief of stricture, and is by 
far the safest method, death never having followed 
its employment. In soft recent strictures the num- 
ber of permanent cures resulting from gradual dila- 
tation compares favorably 'with those treated by 
internal urethrotomy, without incurring the risk 
attendant upon the latter operation. 
To perform gradual dilatation properly the char- 
acter, position, and caliber of the stricture should 
be closely ascertained by means of the bougie a 
boule. If possible, the operator should commence 
dilatation while the caliber of the stricture is not 
dense. The instrument to be used should be a 
conic steel bougie one or two sizes smaller than the 
contraction, as more or less hyperesthesia of the 
urethra usually exists, and the onward progress of 
an instrument large enough to fill or distend the 
stricture gives rise to great pain, causing more or 
less spasm and interfering with the passage of the 
bougie. The canal in the neighborhood of the ob- 
struction is likely to be congested, chronically in- 
flamed, and softened. If there is much distention, 
the mucous membrane is easily lacerated. Lacera- 
tion is followed by pain after micturition, with the 
discharge of more or less blood. In rare cases 
urine is absorbed into the system by reason of 
abrasion or laceration, giving rise to urinary fever. 
By commencing with a bougie of a smaller diam- 
eter than the caliber of the stricture, this complica- 
tion is frequently avoided. The confidence of the 
patient is gained if the instrument produces but 
little pain, and thereby more progress is made than 
if force were used. 
The best rule is to increase the size of the instru- 
ment as the pain of insertion diminishes and as the 
amount of blood following the introduction becomes 
less. The instrument should not be introduced URETHRA (MALE,) STRICTURE 
more frequently than every third day, and should 
be immediately withdrawn after insertion. 
Before using an instrument, both it and the 
urethra itself should be made thoroughly aseptic. 
Palmer has shown the value of boric acid in steriliz- 
ing the urine, administered when the patient is 
placed under treatment. It should be given for 2 
weeks in doses of 10 grains 3 times daily. 
Urinary fever is most likely to occur at the be- 
gining of the treatment, when the mucous mem- 
brane of the canal is in a condition of subacute in- 
flammation and is somewhat softened. This may 
be avoided by the use of boric acid. 
Examination of the urethra by means of the 
endoscope will show how rapidly the inflammatory 
symptoms disappear in the neighborhood of the 
stricture when partial dilatation has been accom- 
plished. This change possibly accounts for the 
rapid amelioration of the local symptoms-indeed, 
it commences after the instrument has been passed 
but a few times, and before the normal caliber of 
the urethra has been restored. 
The length of time the treament should be con- 
tinued will vary with the condition of the obstruc- 
tion to be overcome. If the stricture is extensive, 
about 3 months will be required to restore the 
urethra to its normal size. During this time the 
patient is to be instructed in the use of the instru- 
ment, which he should be directed to pass twice 
a week for a period of 2 months; after which he 
must use it once a week for a similar period, then 
once in two weeks, and finally once a month. The 
treatment may then be discontinued, the patient 
being directed to return to the use of the instru- 
ment whenever there is an indication of a tendency 
to recurrence to an abnormal condition. 
By faithfully employing the instrument when 
necessary, the patient can always keep the urethra 
patulous, and need suffer no further urinary diffi- 
culty. In cases of stricture of very small caliber 
a much longer time will be required to bring about 
permanent good results. Gradual dilatation may 
be employed for years, with every advantage to 
the patient, no symptom of contraction making 
its appearance nor any indication of trouble from 
the prolonged use of the bougie. 
Recent strictures frequently disappear alto- 
gether when the method here prescribed is pur- 
sued, when the further use of the instrument may 
be dispensed with. 
Gradual dilatation is indicated in all cases of 
recent dilatable stricture in any portion of the 
urethra, or when the stricture is not irritable, 
resilient, or nodular. Firm, well-organized bands 
situated within from 3 1/2 to 4 inches from the 
meatus may require other measures for their 
obliteration. 
When diabetes or advanced disease of the kid- 
neys exists, gradual dilatation is far more safe 
than any other method of procedure. This, too, 
is the proper treatment for those suffering from 
debility, or from disease of the heart, and for indi- 
viduals broken down in health, and for the very 
old, especially if chronic urinary fever coexists, 
t * In many cases one of the cutting operations may 
be advised instead of dilatation, but experience 
teaches that when a well-organized stricture 
exists, urethrotomy is as frequently followed by 
recontraction as is dilatation, the patient at the 
same time running the greater hazard that always 
follows a cutting operation, with very little, if any, 
better chance of permanent benefit in his favor. 
It cannot be denied that every urethrotomy is 
attended with more or less risk to the patient, 
while dilatation is perfectly safe; moreover, the 
further the division of the stricture is made from 
the meatus, the greater will be the danger from the 
operation. 
Death has followed shock after simple division 
of the meatus. Even in the hands of the most 
experienced operators the death-rate from internal 
urethrotomy is 2 in every 100 cases. 
Taking the dangers of the cutting methods into 
consideration, and the fact that they are rarely 
followed by permanent results, it would seem to be 
obligatory on the part of the surgeon to give the 
uninformed the option of the safest course. If the 
cure from the cutting operations were radical, and 
if the strictures did not recontract in a large per- 
centage of cases, it would doubtless be the duty of 
the practitioner to allow the patient to run the 
risk of urethrotomy; but as the result is by no 
means certain by any method now employed, 
there should be no hesitancy in recommending a 
course that, while it has its disadvantages, yet 
relieves the symptoms due to obstruction and is 
absolutely safe. * 
2. Continuous Dilatation.-In resorting to con- 
tinuous dilatation, the surgeon should begin with 
a very small instrument, a filiform bougie being 
usually employed. This must be allowed to 
remain in situ for 3 days, when, as a result of the 
continuous pressure, the stricture relaxes suffi- 
ciently to allow of the introduction of a larger 
instrument. As a rule, the tunneled catheter is 
the instrument to be used; this is passed over the 
whalebone and through the obstruction into the 
bladder. After this the surgeon is free to deal 
with the stricture in any manner that he may 
prefer. 
There are two conditions under which this 
method of treatment is applicable: First, when 
there is a stricture of small caliber, usually situated 
in the membranous portion of the canal, and gen- 
erally accompanied by retention of urine; second, 
when, although the stricture is tight, the patient 
is enabled to pass urine with sufficient ease to 
allow him to be prepared for a radical operation. 
In the first instance, when a filiform bougie has 
been inserted, a Gouley tunneled catheter should, 
if possible, be threaded over the whalebone and 
passed through the obstruction, and the urine 
should then be withdrawn. Should the effort to 
pass the catheter be unsuccessful, the filiform 
bougie should be retained in place by means of 
appropriate dressings, so that it cannot be expelled 
from the urethra. If the symptoms are urgent, 
the bladder must be aspirated. If the viscus is 
not overdistended, the patient should be given 1/2 
grain of morphin and should be immersed in a hot 
bath, when he will have but little further trouble 
in passing his urine. The stricture should then 
URETHRA (MALE), STRICTURE URETHRA (MALE), STRICTURE 
URETHRA (MALE), STRICTURE 
be treated as the surgeon may deem most 
expedient. 
Under the second condition, continuous dilata- 
tion is employed simply to enable the operator to 
overcome the contraction by the use of either 
gradual or modified rapid dilatation, or to enable 
him to enlarge the stricture sufficiently to pass a 
Syme's staff, and thus facilitate the performance 
of external perineal urethrotomy, should this 
operation be indicated. 
The failure of many practitioners to use filiform 
bougies successfully arises from various causes: 
the instruments usually sold are often worthless: 
they are too stiff, not well rounded, do not termi- 
nate in a proper neck, and are generally too large 
to be threaded over the smaller sized catheters. 
The surgeon should make his own filiform bougies; 
a dozen, properly constructed, will, with ordinary 
care, last through several years of active practice. 
An important rule to follow is to employ the fili- 
form before any bougie, catheter, or other instru- 
ment has been introduced into the urethra. If an 
instrument has been previously used, it is of very 
little avail to attempt to pass a filiform, as fail- 
ure will generally result. Great patience is a 
necessary element of success. 
It is well first to inject two drams of adrenalin 
solution 1 to 4000, let the patient hold it in the 
urethra for two or three minutes, and then distend 
the canal by gently injecting a syringeful of warm 
carbolized oil before inserting the filiform, which 
has been rendered aseptic, and which is to be 
introduced into the meatus and passed slowly 
down to the obstruction, while at the same time 
the patient's face is carefully watched for the 
slightest expression of pain, which is an indication 
that the onward passage of the filiform must cease. 
The slightest impediment to the passage of the 
bougie should warn the operator that he has pro- 
ceeded far enough with the instrument, when a 
second should be introduced in the same manner, 
and the process thus repeated until 6 or 8 whale- 
bones have been inserted, when the operator very 
gently tries each in turn, to see if he can find the 
opening in the obstruction; beginning on the left 
and passing to the right side of the patient, the 
surgeon naturally tending to work toward himself. 
If the stricture is excentric, the opening will 
probably be found by this manipulation; the 
instrument will glide through the contraction with 
little or no pain, when, without force being 
required, it will pass into the bladder, and will be 
freely movable in the urethra. 
These instruments are frequently made with a 
spiral twist at the end, on the supposition that the 
physician can more readily pass such a one should 
the stricture be excentric. However, perfect suc- 
cess with the straight instrument is always possible. 
In order to successfully insert a tunneled cath- 
eter over the filiform through the stricture, the 
instrument should be gently passed down to the 
obstruction, then transferred from the right to 
the left hand; and while the right hand keeps the 
penis on the stretch, the filiform is to be withdrawn 
about 1/4 of an inch, and then both the filiform 
and the tunneled catheter are to be carried to- 
gether through the contraction. This procedure 
prevents the catheter from cutting the filiform 
into two fragments, and assists in guiding it through 
the obstruction. 
This method of treatment is of great value as an 
adjunct to the employment of more radical meas- 
ures. It is of service in relieving retention of urine 
due to strictures of small caliber, in preparing 
the canal for gradual or modified rapid dilatation, 
and in permitting the passage of a staff for external 
perineal urethrotomy. 
If a stricture exists in the neighborhood of the 
bulbous or membranous portion of the canal, and 
is not irritable, resilient, or nodular, the employ- 
ment of continuous dilatation should be fol- 
lowed by the gradual method; and if this is not 
practicable, modified rapid dilatation is strongly 
recommended. 
3. Modified Rapid Dilatation.-The operation 
to which this name is given is not in favor with 
many genitourinary surgeons, but undoubtedly 
gives good results in strictures of small caliber 
situated in the membranous portion of the urethra. 
The patients thus operated on are confined to the 
house but 4 days, at the end of which time they 
are allowed to go about, with directions to re- 
port to the surgeon at intervals of 3 days in order 
to have a full-sized bougie inserted, which they 
soon learn to use themselves. The treatment is to 
be continued as advised when speaking of gradual 
dilatation. 
■ It is not observed that strictures thus treated 
show any greater tendency to recontract than 
those on which either internal or external urethrot- 
omy has been performed, especially if dilatation 
is continued afterward. 
To carry out this method of treatment properly 
the patient is to be put to bed, the urethra washed 
out with a 4 percent solution of boric acid, and an 
aseptic filiform bougie passed and tied in place. 
The patient is then given 10 grains of boric acid 3 
times daily, and the urethra is to be irrigated daily 
with boric acid solution; at the end of the third day 
he is etherized and the urethra is washed with a 
1:20,000 mercuric chlorid solution. The Thomp- 
son dilator is then passed over the filiform and 
through the obstruction, when, by means of the 
thumb-screw attached to the handle, the blades of 
the instrument are slowly and very gradually sep- 
arated to a very slight degree; after remaining in 
this position for 1 minute they are again approxi- 
mated. 
This procedure of alternate separation and 
approximation is to be repeated, taking care each 
time to separate the blades of the instrument to a 
somewhat greater extent, until the stricture is 
enlarged sufficiently to allow of the insertion of a 
Gross dilator, which requires that the caliber of 
the urethra should not be less than 18 F. 
The Thompson instrument is then removed, and 
the Gross instrument inserted. In the same 
gradual manner the caliber of the urethra is brought 
to the full size of the canal, which has previously 
been ascertained by means of a bougie & boule. 
Strictures so treated are stretched rather than 
lacerated or torn; this is shown by the small URETHRA (MALE), STRICTURE 
URETHRA (MALE), STRICTURE 
amount of hemorrhage that follows. On exam- 
ination with the endoscope two weeks later the 
walls of the urethra will be found to be smooth, 
and not ragged, as would be the case if laceration 
had taken place. 
After the Gross instrument is withdrawn, a 
full-sized bougie is passed, to ascertain whether 
all obstruction has been dislodged; if this is found 
to be the condition, the urethra should be irrigated 
with a 1:20,000 mercuric chlorid solution, and a 
sterilized catheter passed and tied in place; then 
a small quantity of warm boric acid solution is to 
be injected into the bladder. The patient is put 
to bed; the urethra and bladder are to be irrigated 
daily with a warm boric acid solution, and on the 
fourth day the instrument is to be removed and 
a full-sized bougie passed, The patient is allowed 
to sit up, and may resume his vocation on the 
following day. 
This method is applicable to the treatment of 
filiform strictures in the neighborhood of the bul- 
bous and membranous portions of the urethra, 
which are not irritable, resilient, or nodular, and 
which cannot be treated by gradual dilatation. 
It likewise is not convenient when time is an object, 
as, for instance, when the individual is about to un- 
dertake a journey or is about to be married. 
It should not be performed on the aged, or on 
those suffering from disease of the kidney, urinary 
fistula, or abscess of the perineum. In many 
cases in which the stricture is resilient, the caliber 
very small, and a perineal section is indicated, 
this operation may be employed primarily to 
facilitate the passage of the grooved staff, immedi- 
ately afterward performing the cutting operation. 
It would seem that an operation that is so free 
from complications, attended with so little danger 
to life, and that at the same time produces such 
favorable results, with no greater tendency to 
relapse than is to be encountered after other 
methods, is entitled to a prominent place among 
the resources that the surgeon possesses wherewith 
to overcome obstructions in the bulbous and 
membranous portions of the urethra. 
When it is observed that in performing this 
operation the stricture is dilated gradually, and 
that an effort is simply made to restore the con- 
tracted portion of the canal to its normal caliber, 
that it is not overdilated, and that in conjunction 
with the operation the strictest aseptic and anti- 
septic precautions are employed, it will be seen 
that it differs very materially from the method of 
divulsion, which should become obsolete. 
4. Internal urethrotomy should be limited to 
well-organized strictures situated within 3 1/2 or 4 
inches from the meatus. If they are of such 
small caliber that a urethrotome cannot be passed, 
they should be first cut on the roof of the urethra, 
from before backward, and the constriction 
should be divided on the floor of the canal by the 
cross urethrotome, which, being of the shape of a 
bulbous bougie, locates the constricting band with 
great exactness. Stricture of the meatus and of 
the neighborhood of the fossa navicularis should 
be divided on the floor of the urethra, especially 
if they give rise to reflex symptoms. 
5. Dilating internal urethrotomy, though very 
thorough, is not indicated in many instances the 
operation being frequently followed by reforma- 
tion of the stricture. Its sphere of usefulness is 
confined to those conditions in which the stricture 
is well organized, of long standing, situated within 
3 1/2 inches of the meatus, and is either nodular 
or resilient. In the latter condition it is the only 
operation that offers permanent relief; but unless 
the patient employs the bougie in the manner rec- 
ommended when treating of gradual dilatation, 
the contraction will be likely to return. 
Dilating internal urethrotomy should not be 
employed in a case of ordinary stricture of the pen- 
ile portion of the canal, unless it is complicated in 
the manner already described, as the operation 
will probably be followed by a curvature of the 
penis, which may last for a period ranging from 
6 weeks to a year, and is, of course, a source of 
great mental anxiety to the individual. What is 
far worse is that the knife of the instrument cuts so 
deeply that an extensive division of the muscular 
fibers of the urethra follows, and, as a result, drib- 
bling after the act of micturition takes place; as 
the canal is unable to expel the last drops of urine, 
it slowly oozes from the meatus. This condition 
is permanent. 
If it can be avoided, dilating internal urethrot- 
omy should not be performed on persons suffering 
from impotence, neurasthenia, abnormal nocturnal 
losses, or sexual hypochondriasis. Very naturally, 
the incurvation of the penis and the dribbling of 
the urine produce very depressing mental effects 
on the patient, which are difficult to overcome. 
When these complications exist, it is preferable to 
rely upon internal urethrotomy by means of the 
Gross instrument. 
6. Dilating internal and external perineal ure- 
throtomy is relied upon for the relief of nodular 
strictures of the penile portion of the urethra, and 
of strictures of the bulbous portion of the canal. 
The object in opening the membranous portion of 
the canal, in cases of nodular strictures situated 
in the anterior portion of the urethra, which 
have been divided, is that the parts may be 
put at complete rest, and that the indurated 
tissue of which they are formed may be allowed 
to undergo fatty degeneration, atrophy, and 
absorption. 
Dilating internal and external perineal urethrot- 
omy has frequently been modified, with good 
results. The strictures upon which this method 
was resorted to were situated about 2 1/2 inches 
from the meatus, were nodular, resilient, and of 
very small caliber. By means of the Maisonneuve 
instrument they were divided on the roof of the 
canal, and the insertion of the Otis dilating ure- 
throtome thus permitted; the constricting bands 
on the floor were freely divided, and the caliber of 
the urethra brought to its full size. A Jacques' 
catheter was then passed, fastened in place, and 
allowed to remain in situ for 2 weeks, temporarily 
removing it every third day for the purpose of 
sterilization. The urethra and bladder were daily 
irrigated with a boric acid solution. The indura- 
tion around the seat of the stricture disappeared, URETHRA (MALE), STRICTURE 
URETHRA (MALE), STRICTURE 
and the patients recovered without complicating 
the cases by the addition of perineal puncture. 
7. External Perineal Urethrotomy by Means of a 
Guide.-The membranous urethra is opened, the 
surgeon being guided in reaching that portion of 
the canal by either the filiform bougie, a Gouley 
tunnel catheter, Thompson's dilator, or a Syme's 
staff. This operation is indicated in nondilatable, 
resilient, nodular strictures of small caliber, in 
associated with fistulse and abscesses, and when 
false passages exist, with retention of urine. It 
may be performed by carefully dissecting down 
upon the urethra until the obstruction is found, 
and then cutting through the stricture, a procedure 
known as the "Wheelhouse operation." Another 
method is sometimes employed, known as " Cock's 
operation." 
With the aid of a modification of the Wheelhouse 
Syme's Staff. 
Otis' Dilating Urethrotome. 
Otis' Urethrometer. 
Gross' Dilator. 
obstructions of the canal associated with fistulee 
and abscesses of the perineum, and in conjunction 
with internal urethrotomy performed upon some 
part of the penile portion of the urethra. 
8. External perineal urethrotomy without a 
guide, generally known as "perineal section," is 
performed when no guide of any kind is passed into 
the canal. It is generally employed in the cases of 
stricture of traumatic origin, of obstructions 
staff designed by Horwitz, the operation known 
by the name of that surgeon is very materially 
altered and simplified. Horwitz's staff consists of 
two blades in close approximation, which together 
form a smooth rod with a thumb-screw at one end, 
by means of which the blades may readily be 
separated, working upon the same principle as the 
Otis dilating urethrotome. The distal end of the 
instrument terminates in a rounded nut, which can URETHRA (MALE), STRICTURE 
URETHRA (MALE), STRICTURE 
be removed or replaced by a whip filiform; the nut 
on the end is tunneled, so that an ordinary whale- 
bone filiform can be passed. The filiform is em- 
ployed when it is not possible to insert the whip 
bougie, as it frequently happens that the former 
instrument can be introduced when the passage of 
the latter cannot be achieved; so that the staff can 
be employed with either an ordinary filiform or a 
whip bougie, or without any guide. 
When it is possible to introduce the whip bougie 
through the stricture, it is to be fastened to the 
perineal staff. The blades of the instrument are 
closed and then passed into the urethra until 
arrested by coming in contact with the shoulder 
of the stricture. The whip bougie being pushed in 
front of the staff, reaches the bladder and curls up, 
and when the urethra is opened, serves as a guide to 
the operator, as it passes directly through the 
stricture. 
In case the whip bougie cannot be passed 
through the stricture, a whalebone filiform should 
be inserted; the tunnel at the end of the staff is 
threaded over with a filiform and is introduced into 
the urethra until arrested at the contracted portion 
of the canal. 
By means of the thumb-screw the blades are 
separated, and thus the urethra in front of the 
stricture is not only fixed, but is made prominent, 
and the operator, after making the incision through 
the skin, can readily open the urethra with absolute 
precision and ease. 
If the stricture is impassable and the operation 
must be performed without a guide, the staff is to 
be passed down to the seat of contraction; when 
this point is reached, the blades are to be separated 
and the urethra fixed and made prominent, when 
the urethra can be opened in front of the stricture 
by a few touches of the knife. The modification 
in the techinc of perineal section will now be 
considered. 
When the patient is placed on the operating 
table, an effort is to be made to introduce the whip 
bougie; should this fail, a filiform is inserted, over 
which is threaded the perineal staff, which is passed 
down to the strictured portion of the urethra; the 
blades are then separated and the instrument 
given to an assistant to hold, who at the same 
time lifts the scrotum well out of the way. The 
individual is then placed in the lithotomy position, 
the buttocks projecting slightly beyond the edge 
of the table. A free incision is made along the 
perineal raphe, and the structures overlying the 
urethra are divided until the canal is exposed at 
the bottom of the wound. A tenaculum is then 
passed into the urethra on each side of the staff, 
and placed in the hands of the assistant who has 
charge of the leg, with directions to make gentle 
traction; this brings the urethra prominently into 
the wound, where it can be readily incised in front 
of the stricture, when the staff is exposed in situ. 
The Wheelhouse probe is then utilized to search 
for the mouth of the stricture; as soon as it is dis- 
closed, the probe is to be inserted by the side of the 
filiform and passed backward until it enters the 
bladder; it is then handed to an assistant to hold. 
With the index-finger of the left hand in the 
rectum as a guide, and in order to prevent injury 
to the bowel, a probe-pointed bistoury is passed 
along the groove on the under surface of the staff, 
so as to divide the stricture throughout its entire 
length; after which a Teale gorget is to be inserted 
beside the probe until the instrument enters the 
bladder. The probe is then to be removed and a 
soft-rubber catheter passed through the penile 
urethra until the point of the instrument appears 
in the perineal opening, when it is to be seized by 
the surgeon between his finger and thumb, pulled 
well into the incision, and made to pass along the 
gorget until it reaches the bladder; the urethra, 
perineal wound, and bladder are then to be irrigated 
with a solution of 1:20,000 bichlorid of mercury, 
and the perineal wound dressed in the usual 
manner. 
In cases in which neither a whip bougie nor a 
filiform can be made to pass the stricture, a method 
precisely similar to that just described should be 
pursued. It sometimes happens that, owing to 
infiltration against the compact tissue, it is impos- 
sible, after the most careful search, to find the 
proximal end of the urethra. Should the operator 
be unable to discover the opening to the strictured 
portion of the canal, the bladder should be opened 
after the method suggested by Cock. If the 
patient is in poor physical condition, or if suffering 
from chronic disease of the kidney, or if he has 
sustained a rupture of the urethra, with infiltra- 
tion of urine, valuable time should not be wasted in 
attempting to reach the bladder through the 
perineum; the proper method is to proceed at once 
to perform retrograde catheterization. 
Cock's Operation.-The surgeon having failed to 
pass any instrument through the strictured portion 
of the urethra to serve as a guide, the patient is to 
be placed in the lithotomy position; the index- 
finger of the left hand is introduced into the rec- 
tum, and its tip kept in contact with the apex of 
the prostate gland. A double-edged knife is then 
thrust directly into the median line of the perineum 
about one inch above the sphincter ani, and carried 
toward the tip of the finger in the rectum, opening 
the urethra at the junction of the membranous and 
prostatic portions of the canal. 
9. Electrolysis.-Of 15 cases treated by this 
means, all did badly: either urethritis, prostatitis, 
cystitis, or epididymitis followed; and this mode 
of treatment was necessarily abandoned. In one 
case slight improvement followed; this was due to 
the gradual dilatation produced by the electrode. 
Fort, of Paris, has devised special instruments for 
this operation, from the use of which he claims to 
have obtained most excellent results. The ex- 
perience of genitourinary surgeons throughout the 
United States is against its general adoption or its 
value in ordinary cases. It is therefore not 
recommended. 
10. Urethrectomy.-This treatment is reserved 
for traumatic strictures, attended by great resili- 
ency, which promptly recontract, in spite of every 
effort, after a most thorough and complete opera- 
tion. It consists in either partial or complete 
excision of all the nodular and strictured tissue, 
which is dissected away by means of an incision in URETHRAL CALCULUS 
URICACIDEMIA 
the perineum, a new urethra being formed around 
a retained catheter. 
11. By divulsion is understood the passing of a 
dilator so as to rupture the contracting band. 
Divulsion of a stricture by Holt's instrument is 
generally condemned as dangerous to life, as has 
been abundantly proved by a large mass of 
clinical testimony. Safer methods offer better 
results. 
URETHRAL CALCULUS.-Calculi are occa- 
sionally formed in the urethra, in the dilated and 
fasciculated pouch that develops behind a stric- 
ture; but the nucleus is nearly always carried 
down from the bladder. The symptoms depend 
upon the degree of obstruction: if the calculus is 
large enough to occlude the urethra itself, or is so 
sharp and angular as to bring about the same 
result by the spasm that it excites, retention 
occurs; and if speedy relief is not given, ulceration 
and extravasation follow. If, on the other hand, 
it is small and is lodged in a diverticulum, it may 
continue to increase from the deposit of phos- 
phates on its surface, and to wear its way into the 
tissues, until at length it forms an enormous mass, 
lying in the substance of the penis, alongside 
the urethra, almost buried under the mucous 
membrane. 
Impacted calculus is more common in children 
than in adults, owing to the greater frequency of 
stone in childhood and to the small size of the 
urinary passages. The calculus is washed down 
from the bladder during the act of micturition and 
is suddenly arrested, generally in the membranous 
part or at the meatus. 
Symptoms.-The stream stops suddenly, there 
is a sharp, cutting pain at the end of the penis, 
with violent straining, and perhaps a few drops of 
blood exude from the urethra, especially if the 
calculus is sharp and angular. For a time the 
straining continues, the bladder becomes more and 
more distended, and then either sudden extrava- 
sation occurs, or, if a small quantity of urine can 
escape by the side, so that there is not such 
immediate tension, inflammation sets in, ending 
in urinary abscess and fistula. 
Diagnosis.-There is seldom difficulty in the 
diagnosis. The history of the case, the way in 
which the child screams and pulls at the end of its 
penis, the retention of urine, which is so rare in 
children from any other cause, and the few drops 
of blood are distinctive. Very often the calculus 
can be felt from the outside. If it cannot be 
felt, a small catheter may be passed down the 
urethra; sometimes it comes to an abrupt stop 
against the stone; sometimes it slips by the side of 
it with a rough, grating sensation, and, entering 
the bladder, gives relief for the moment. If any 
time has elapsed since the accident, the bladder 
may be distended up to the pubes; or there may 
already be a swelling in the perineum, due to 
inflammation and commencing extravasation. 
Treatment.-A calculus in the penile part can 
generally be worked forward with the fingers until 
it reaches the orifice, when a small incision may be 
necessary to extract it. If this is not successful, 
a scoop or pair of urethral ("alligator") forceps 
may be passed down the urethra, and an attempt 
made to draw the calculus forward; but this may 
inflict serious injury upon the mucous membrane. 
If it is fixed or is too far back for this, the patient 
should be placed in the lithotomy position, the 
skin over the projection stretched with the finger 
and thumb of the left hand, and a small median 
incision made down upon it. Generally the calcu- 
lus springs out at once, and the wound may be 
left to granulate. The bulb should, if possible, 
not be incised. If the calculus is near the neck of 
the bladder, it should either be removed by the 
median operation or pushed further back and 
crushed with a lithotrite. 
URETHRITIS.-See Gonorrhea. 
URETHROSCOPE.-See Endoscope. 
URETHROTOMY.-See Urethra (Male) 
(Stricture). 
URIC ACID.-See Uricacidemia, Urine (Ex- 
amination) . 
URICACIDEMIA.-A constitutional disease 
arising from disturbed metabolism and an accu- 
mulation of uric acid in the blood, and character- 
ized by an excess of uric acid in the urine, by dis- 
turbed digestion, and by various nervous symp- 
toms. It differs from gout chiefly in the absence 
of deposits of urates in the small joints and in the 
absence of localized manifestations. 
Synonyms.-Lithemia; lithic acid diathesis; uric 
acid diathesis; latent gout; lithuria. 
Etiology.-Hereditary influences, overeating, 
alcoholic excess, impaired digestion, sedentary 
habits, insufficient exercise, and mental anxiety, 
with loss of sleep are the principal causes. 
Symptoms.-It may be said that, as a rule, in 
lithemia the nervous symptoms are vague, such as 
insomnia, pains in the lumbar region, headache, 
neuralgia, and mental hebetude. The circulation 
is sluggish, and the patient complains of cold feet. 
Tonsillitis is common. 
Gastrointestinal Symptoms.-In these cases con- 
stipation exists, and the tongue is furred. The 
appetite may be poor or sometimes may be abnor- 
mally large. The digestion is always bad and 
gastralgia and acid dyspepsia may coexist. 
Urinary Symptoms.-In nearly every case the 
urine is loaded with uric acid and the urates. The 
urine is usually high colored, scanty, acid in reac- 
tion, and may cause pain on micturition. See 
Urine (Examination). 
Sequels.-Arteriosclerosis, interstitial nephritis, 
cirrhosis of liver, gastralgia, dyspepsia, and prob- 
ably nerve lesions not yet understood. 
Diagnosis.-There are but few diseases in which 
the importance of the examination of the urine is 
greater. A disease with such vague nervous and 
gastrointestinal symptoms may simulate any 
number of other affections, including malaria 
(very common), rheumatism, and diseases of the 
brain and of the spinal cord. 
If uric acid is present in a sample of urine, it is 
not absolutely diagnostic of lithemia; but with the 
history and other symptoms it is not likely that 
the diagnosis will be mistaken. Next in impor- 
tance to the examination of the urine is a correct 
and complete history. It is very often a disease URIDROSIS 
URINARY CALCULI 
of neglect, and the patient, as a rule, does not 
consult the physician until its progress has far 
advanced, and until the accumulation of the uric 
acid in the system produces the manifold symp- 
toms which each patient can so accurately 
portray. 
Treatment.-Few diseases yield so rapidly to 
proper treatment, and a system of hot baths, 
salines, cathartics, and diuretics may yield truly 
brilliant results. Meats, coffee, tea, alcohol, malt 
liquors, and especially tobacco are to be restricted 
to the greatest degree, and foods easily digested 
are indicated. All kinds of fruit and vegetables 
may be eaten, and the diet should be composed 
principally of these articles. Fats and desserts 
should be shunned. The bowels, kidneys, and the 
skin must be kept active by medicines, massage, 
and the proper amount of outdoor exercise 
For the constipation: 
I). Tincture of nux vomica, 3 ij 
Fluidextract of cascara, 3 jss 
Glycerin, enough to make 3 iij. 
One teaspoonful at bedtime. 
Constipation may often be relieved by a pill 
containing: 
I). Strychnin, gr. ss 
Extract of belladonna, gr. iij 
Aloin, 3 ss. 
Divide into 30 pills. One pill 3 times daily. 
Purgative salines may be used, such as Carlsbad 
salts (1/2 ounce), Rochelle salts, or any of the 
purgative or laxative mineral waters, such as the 
Hunyadi and Apenta. Sodium phosphate may be 
given morning and night. For the kidneys almost 
any diuretic may be given. Free use of drinking- 
water is advisable. 
To keep the skin active, hot baths should be 
taken in the middle of the day, 3 times a week. 
Thorough massage following the baths greatly 
enhances the value of this treatment. See Acid- 
ity, Autointoxication. 
URIDROSIS.-See Sweat Glands. 
URINARY CALCULI.-Urinary calculi are 
found in the kidney, ureter, bladder, and urethra. 
They may be formed from any of the sediments 
that occur in urine, but the tendency is much 
greater in the case of some-uric acid, for example 
-than in the case of others, such as phosphate of 
lime. The animal matter that holds the particles 
together is derived from the mucus of the urinary 
tract, which undergoes a process of fermentation, 
and either collects layer after layer of uric acid or 
leads to the formation of sparingly soluble oxalate 
of lime. 
Origin.-The nucleus of a calculus may be hol- 
low or may consist of dried blood; in most calculi, 
however, it is formed of uric acid or oxalate of lime, 
held together by a colloid material. These are of 
renal origin, though they subsequently increase 
by the deposit of laminae as they lie in the pelvis 
of the kidney or in the bladder. Those formed of 
triple phosphates are only thrown down when the 
urine becomes ammoniacal, and usually, therefore, 
originate in the bladder, though they are not con- 
fined to it. Nuclei of uric acid are most common 
in early childhood and in late adult life, especially 
if there is a tendency to gout. The starting-point 
is the deposit of crystals in the secreting tubules, 
and most likely in the actual cells; infarcts of uric 
acid are often present in the renal tubules of infants 
shortly after birth; and in gout all stages can be 
traced, from crystals to the cells and irregular 
masses in the tubules of the medullary part, to 
minute calculi projecting from the orifices on the 
pyramids or lying loose in the cavity of the pelvis. 
The cause of the precipitation is probably some 
impairment in power of the cells, whether this 
arises from weakness, from exhausting illness, or 
from long-continued overwork, as in gout; .and it 
is assisted by everything that tends to check the 
flow of urine, whether it is the small size of the 
secreting passages, as in children, or an actual 
obstruction, such as an enlarged prostate. When 
once the pelvis of the kidney or the bladder is 
reached, the nucleus increases by acting as a focus 
around which are deposited layers that differ 
according to the reaction and composition of the 
urine. 
Very little is known with regard to the formation 
of renal calculi, with the exception of those com- 
posed of triple phosphate, which may be formed 
around anything that causes decomposition of 
urea. In children of the poorer classes calculi are 
more common than among the well-to-do, and are 
nearly always composed of uric acid; possibly this 
arises from a deficient supply of milk and from 
improper diet. Gravel, too, is chiefly found 
among those who have a tendency to gout, or 
those who consume large quantities of animal food, 
or those who are addicted to the use of alcohol; 
but though this points in a general way to increase 
in the tissue waste, and to the effects of indigestion, 
acidity, and malassimilation, in causing the pre- 
cipitation of sediments in the urine, something 
more is needed to explain the formation of calculi. 
There must be some condition of the urinary 
organs leading to the production of the colloid 
material necessary to cement the particles together. 
Calculus is more common in the male than in the 
female; and this cannot be altogether explained 
by anatomy, as the same holds good with regard 
to the kidneys, although to a less extent. Heredi- 
tary influence probably does exist, even after full 
allowance has been made for the effects of locality 
and for similarity of habit. 
Physical Characteristics.-Calculi vary in size 
from minute bodies, somewhat larger than gravel, 
to masses of more than a pound in weight. The 
smaller calculi are frequently numerous; the 
larger masses are single. 
The following is a table of the characteristics 
of calculi (Moullin): URINARY CALCULI 
URINARY STREAM, ALTERATIONS 
- 
Shape and Size. 
Surface. 
Fracture. 
Color. 
- 
1. Uric acid.... 
Ovoid or round, vary- 
ing in size from 
gravel to that of a 
hen's egg, or even 
larger. 
Smooth or slight- 
ly granular. Sus- 
ceptible of a 
fairly high pol- 
ish. 
Crystalline in pro- 
portion to purity. 
Brittle, but hard. 
Yellow to red or 
reddish-brown. 
Uric acid calculi are the 
most common of all, 
and are always de- 
posited in acid urine. 
Usually they occur at 
the extremes of life. 
2. Urates 
Ovoid, rarely as large 
as the former; often 
multiple. 
Smooth and 
earthy. 
Earthy and inclin- 
ed to crumble. If 
it forms the whole, 
homogeneous; but 
in general much 
laminated. 
Fawn colored or 
whitish-gray. 
Most common in chil- 
dren, mixed with lime 
oxalate. Gen e r a 11 y 
acid urate of soda, but 
sometimes of lime and 
ammonia. 
3. Oxalates 
Irregular, sometimes 
in the form of hemp- 
seed calculi. 
Tuberculated.... 
Crystalline and very 
hard. 
Dark brown, and 
even black, from 
repeated hemor- 
rhages. 
Usually layers of oxa- 
late with others of uric 
or urates. Very often 
coated with phosphates. 
4. Mixed phos- 
phates. 
5. Phosphate of 
lime, or bone 
earth. 
Depend on that of 
nucleus. 
Rarely of any size.... 
Smooth and fri- 
able. 
Smooth and soft. 
Chalky, soft, and 
breaking easily. 
Occasionally small 
crystals on the 
surface. 
Breaking easily, 
with crumbling 
fracture. 
White or gray... 
White. 
Only deposited after de- 
composition of the urea. 
6. Cystin 
Ovoid and generally 
of medium size. 
Finely granular, 
with small yel- 
low crystals over 
it. 
Soft and crystalline. 
Yellow, turning 
pale green after 
exposure, with 
a somewhat ra- 
diated appear- 
ance. Waxy. 
Usually pure, but some- 
times on a uric acid 
nucleus- 
Analysis. 
Incineration. 
Murexid 
Test. 
Final Test. 
Nature of 
Calculus. 
Melts and leaves a fixed resi- 
Purple color... 
Yellow flame when burned 
Sodium urate. 
due. 
Melts and leaves a fixed resi- 
Purple color... 
Violet flame when burned 
Potassium urate. 
due. 
Melts and leaves a fixed resi- 
No purple 
Dissolve residue in acetic acid: add ammonia in excess- 
Ammonio - magne- 
due. 
color. 
white, crystalline precipitate. 
sium phosphate. 
Melts and leaves a fixed resi- 
due. 
Does not melt, but leaves a 
fixed residue. 
No purple 
color. 
Purple color... 
Residue insoluble in acetic acid. Dissolves in HC1; add 
ammonia-white precipitate. 
Dissolve residue in dilute HC1; add ammonia until alka- 
line, then ammonium-carbonate solution. 
(a) White precipitate 
(6) No precipitate 
Calcium phosphate 
Calcium urate. 
Magnesium urate. 
Does not melt, but leaves a 
fixed residue 
No purple 
color. 
Residue dissolved in water is not alkaline. Dissolves in 
HC1 without effervescence. Ammonia in excess causes 
a white precipitate. 
Calcium phosphate. 
Does not melt, but leaves a 
fixed residue. 
No fixed residue 
No purple 
color. 
Purple color... 
The calculus is insoluble in acetic acid, but the residue 
dissolves with effervescence. 
The calculus dissolves with effervescence in acetic acid.. 
Mix powder with lime and moisten. 
(1) Ammonia is evolved and red litmus paper becomes 
blue in the vapor. 
(2) No ammonia 
Calcium oxalate. 
Calcium carbonate. 
Ammonium urate. 
Uric acid. 
No fixed residue 
No purple 
color. 
Nitric acid solution grows yellow with evaporation. 
Residue insoluble in potassium carbonate. 
Xanthin. 
No fixed residue 
No purple 
color. 
Nitric acid solution turns dark brown. Residue soluble 
in ammonia. 
Cystin. 
No fixed residue 
No purple 
color. 
The soft calculus grows brown when dry and soft again 
with heat. Soluble in ether and residue grows violet on 
heating. Soluble in nitric acid, with slight bubbling; 
no change of color. 
Urostealith. 
See Bladder (Stone), Kidney (Stone). 
URINARY STREAM, ALTERATIONS. Projective 
Force of the Stream.-A strikingly strong stream is 
characteristic of a pathologically developed detru- 
sor, due to hindrances to micturition in the urethra 
canal, such as follow moderate strictures, a nar- 
row external orifice, or from spasm of the detrusor. 
A weakening of the projective force of the current is, URINE, EXAMINATION 
URINE, EXAMINATION 
at a certain age, pathognomonic of prostatic hyper- 
trophy, and is seen in weakening of the detrusor 
from chronic inflammation of the mucous mem- 
brane and muscular tissue, from neglected gonor- 
rhea, in atony from fatty degeneration of the 
muscular tissue, as in the course of acute infectious 
diseases, as typhoid fever or dysentery, and from 
voluntary retention of the urine when micturition 
is painful, as in stone in the bladder and fissures of 
the neck of the bladder. A decrease of force is 
observed in neurasthenics and in spinal diseases 
and tabes. 
Decreased Caliber of the Stream.-Hypertrophy 
of the prostrate; or stricture, will diminish the 
caliber. In prostatics the current falls vertically, 
and in stricture as well; but in the former the force 
is not increased by pressing, while in the latter it is. 
Spasmodic contractions of the urethra, from 
general diseases, may also cause a diminution of 
the caliber. 
Altered Form of the Stream.-A deviation from 
the round form is observed as the earliest sign of 
stricture. In decreased force of expulsion the 
form is changed. Change of form is not a certain 
sign of stricture. 
Continuity of the Stream.-Sudden stopping of 
the stream is supposed to be pathognomonic of 
stone, but it is rarely observed except in children. 
If in adults, the stone must be very small and light. 
It is sometimes noticed in spasm of the sphincter in 
neurasthenics. 
Starting the Stream, etc.-A drop-by-drop pas- 
sage of the urine is characteristic of great stricture 
and great pressure. In some cases there follows a 
round and strong stream when it started drop by 
drop (spasm of sphincter). 
Dripping of Urine.-Dripping of the urine after 
passage of the stream is a frequent occurrence, and 
is of varing importance according as it appears 
after voluntary urination-a short time after or in 
the intervals. It is due to a relaxation of the mus- 
cular tissue of the urethra, and the urethra lying in a 
half-opened condition does not press the urine out 
of the bulbous portions, so that it accumulates and 
is suddenly ejected after urinaton, or it drips away 
slowly during walking. Narrow strictures also 
cause it, when the portion posterior to the stricture 
fills like a sack, and unless emptied by milking 
movements by the patient, it drains away after- 
ward. Abnormal narrowness of the orifice or very 
great phimosis are other causes. Involuntary 
urination may occur at any time, while dripping 
only follows urination. 
URINE, EXAMINATION.-The principal duty of 
the kidney is to eliminate the waste products of 
the body arising from normal katabolism. To this 
end excrementitious material is constantly being 
absorbed from the fluids and tissues of the body, 
and the same is constantly thrown off through 
the medium of the kidneys, which have 
been accurately denominated the "sewers 
of the human system." By an examination 
of the urine, therefore, some idea of cellular 
activity may be formed, as well as of the 
character of such action as it occurs in the 
living organism. 
Average Composition of Normal Human Urine 
(Wormley). 
(Parts in 
1000.) 
Voided Daily. 
Grains. 
Grams. 
Water, 
. 950.00 
Urea 
.. 28.00 1 
Organic 
520.80 
35.00 
Uric acid, 
0.60 
matter 
11.16 
0.75 
Hippuric acid,.... 
. 0.35 
37.60 
6.51 
0.44 
Creatinin, 
0.65^ 
12.09 
0.81 
Extractives, 
8.00 
148.80 
10.00 
Sodium chlorid,. .. 
8.00 
148.80 
10.00 
Phosphoric acid,... 
2.00 
Inorganic 
37.20 
2.50 
Sulphuric acid 
1.25 
matter, 
23.45 
1.56 
Lime, CaO, 
0.25 
12.40 
4.65 
0.31 
Magnesia, MgO,... 
0.30 
5.58 
0.37 
Potash, KsO, and . 
soda, NazO, 
0.60 
11.16 
0.75 
1000.00 
930.20 
62.49 
(Parts in 
Voided 
Daily. 
1000.) 
Grains. 
Grams. 
Water 
... 950.00 
Organic matter 
... 37.60 
699.36 
47.00 
Inorganic matter 
... 12.40 
230.64 
15.49 
1000.00 
To find the proportion of solids in the urine 
use Bird's formula: The last two figures of the 
specific gravity of urine nearly represent the 
number of grains of solids to the ounce contained 
in the urine. The same two figures multiplied by 
2 (Trapp's factor) give the parts in 1000. Haeser's 
factor is 2.33. 
Chemic Examination of Urine 
By the chemic examination of urine is ascer- 
tained the (1) quantity; (2) color; (3) odor; (4) 
reaction; (5) specific gravity; (6) freezing point. 
Also the presence or absence of (7) albumin; (8) 
glucose; (9) indican; (10) peptone; (11) propeptone; 
(12) acetone; (13) diacetic acid; (14) various color- 
ing-matters, as bile; (15) the amount of urea; (16) 
various ingredients, as mucin, fibrin, inosite, sugar 
of milk, etc.; (17) urinary calculi. 
Quantity.-The whole amount of urine passed 
within 24 hours must be collected. The normal 
quantity of urine passed within this time ranges 
from 40 to 50 ounces, or 1200 to 1500 c.c. The 
quantity is increased in winter and is less in sum- 
mer, when there is more evaporation from the skin. 
The quantity is lessened in fevers and in ex- 
haustive diseases. 
CLINICAL SIGNIFICANCE OF VARIATIONS IN THE 
VOLUME OF THE TWENTY-FOUR HOURS 
URINE.-{Bartley.) 
Interstitial nephritis. 
Amyloid degenera* 
tion. 
Increased Volume. 
Renal 
affections. 
Nutritive 
disorders. 
Diabetes mellitus. 
Diabetes insipidus 
(phosphaturia). 
Polyuria (V+) 
Nervous 
Hysteria. 
Essential. 
Epilepsy. 
Dementia. URINE, EXAMINATION 
URINE, EXAMINATION 
In febrile 
diseases. 
Dermatitis. 
Gout. 
Toxic conditions. 
Odor.-Faintly aromatic; rendered strong after 
eating certain vegetables, as asparagus. 
Reaction.-Normally, the urine has an acid 
reaction, due chiefly to acid sodium phosphate. 
Uric, hippuric, and lactic acids also aid in render- 
ing the urine of an acid reaction. In herbivora 
the urine is alkaline in reaction, and in carnivora 
very acid. A vegetable diet causes an alkaline 
urine. On standing, urine undergoes ammoniacal 
decomposition, rendering the reaction alkaline. 
To determine its reaction, red and blue litmus 
papers are used; if the urine is acid, it turns blue 
litmus red; and if alkaline, it turns red litmus blue. 
Specific Gravity.-The specific gravity of normal 
urine varies from 1015 to 1025. When the specific 
gravity is above 1030, glucose should be suspected; 
or when below 1010, albumin. However, the 
solids dissolved in the urine determine to a great 
extent its specific gravity, and a sample of urine 
may vary from 1015 to 1025 and contain albumin 
or glucose. For the determination of the specific 
gravity of urine the urinometer is generally used. 
In order to determine the accuracy of the in- 
strument, it should be placed in distilled water 
at 60° F., when it should sink to the mark 0 
or 1000. 
Decreased Volume. 
Oliguria. (V -) 
Of the heart. 
Of respiratory organs 
Of the kidneys. 
Of the liver and 
uterus. 
In chronic 
affections. 
Calculus or tumor. 
Certain forms of nephritis. 
Nervous anuria. 
Traumatic anuria. 
Suppression, or 
anuria 
Before beginning to collect the specimen of 
urine, the patient should first empty the bladder. 
Should any urine be lost at stool, it must be ap- 
proximately estimated and included in the total 
quantity. 
Color.-Normal urine is pale yellow. Dark 
amber urine frequently contains large quantities 
of uric acid. 
The color may be changed to black by the 
administration of carbolic acid or naphthalin, 
or to yellow after the administration of santonin. 
In malarial fevers of a pernicious type it is fre- 
quently bright red from dissolved hemoglobin. 
The following is a table of colors of the urine: 
Color. 
Cause of the 
Color. 
Pathologic Condi- 
tion or Cause. 
Nearly colorless- 
Dilution or dimin- 
ished pigments. 
Various nervous con- 
ditions, hydruria, dia- 
betes mellitus, dia- 
betes insipidus, con- 
tracted kidney. 
Normal color be- 
Unknown; glyco- 
Sometimes in pul- 
coming black on 
standing. 
suric acid. 
monary tuberculosis. 
Pathology unknown. 
Milky 
Fat globules; pus 
corpuscles. 
Chyluria; fatty kid- 
ney; purulent dis- 
ease in the urinary 
tract. 
Dark amber to 
Increase of nor- 
Fever; pernicious ane- 
reddish-brown. 
Yellow. 
Orange. 
mal or occur- 
rence of patho- 
logic pigments; 
concentration of 
the urine. 
Excreted drugs: 
e. g., picric acid. 
Excreted drugs: 
e.g., santonin, 
chrysophanic 
acid. 
mia; excessive 
sweating. 
Brown to black. 
Hematin, methem- 
Small hemorrhages; 
• 
Brownish-yellow 
to red, becom- 
ing blood-red 
on adding alka- 
oglobin, m e 1 a- 
nin, hydrochinon, 
and catechol. 
Substances intro- 
duced with senna, 
rhubarb, and 
chelidonium. 
methemoglobinuria; 
antipyrin; chlorate of 
potassium; melanotic 
sarcoma; carbolic 
acid; creosote. 
lies. 
Red or reddish. 
Hemoglobin or 
free blood. 
Pigments in food: 
e. g., logwood, 
madder, bilber- 
ries, fuchsin. 
Hemoglobinuria or 
hematuria. 
Greenish to 
Bile pigments. 
Jaundice. 
brown or black. 
Dirty green or 
Dark serum on 
Cholera; typhus; 
hepatic and intes- 
tinal affections. 
Especially marked 
in stale urine. 
blue. 
surface and blue 
deposit due to 
indigo-f o r m i n g 
substances. 
a. Squibb's Urinometer and Jar. 
b. Section of Same. 
Freezing-point.-See Cryoscopy. 
The following table from Bartley is of service:- 
THE URINE OF THE TWENTY-FOUR HOURS- 
NORMAL AND PATHOLOGICAL. 
Physical 
Character. 
Normal. 
Alterations in Ab- 
normal Conditions. 
Color 
Pale straw to 
reddish yel- 
low. The 
average color 
is amber. 
Colorless: neuroses, chronic 
nephritis, diabetes. 
High-colored: acute fevers, 
icterus. 
Blood-red: blood or foreign 
color. 
Dark brown: hematuria, 
poisoning by carbolic acid, 
potassium chlorate, or 
iodoform. 
Smoky brown: presence of 
decomposed blood, acute 
nephritis. 
Yellow or green: presence 
of bile. 
White: chyle or pus. URINE, EXAMINATION 
Physical 
Character. 
Normal 
Alterations in Ab- 
normal Conditions. 
Organic 
Constituents. 
Amount 
in Grains. 
Alterations in Patho- 
logical Conditions. 
Transparency.. 
Consistence.... 
Odor 
Reaction 
Clear, with 
o n ly a slight 
flocculent 
cloud of mu- 
cus. 
When normal, 
urine is mo- 
bile, like 
water. 
Peculiar to it- 
self. 
Slightly acid; 
becomes 
more acid 
on standing, 
then b e- 
comes alka- 
line. 
Urine turbid when passed, 
is abnormal. Whitish 
sediment may be pus, 
phosphates, or ammoni- 
um urate. 
When viscid, it indicates 
albumin, bile, mucus, or 
pus. 
Urine putrid when passed, 
indicates cystitis. 
Urine strongly acid in 
fevers and inflammations 
of the liver, heart, and 
lungs; in acid dyspepsia 
Urine is alkaline in cysti- 
tis, and occasionally in 
debility, chlorosis, certain 
organic nervous diseases, 
typhus, etc. 
Urea 
Uric acid 
Hippuric acid.. 
Creatinin 
Xanthin Bases. 
Carbolic acid, 
Cresol, etc. 
Indoxyl 
Acetone 
Diacetic acid, 
Hydroxybuty- 
ric acid. 
Albumin 
Albumose 
Peptone 
Dextrose 
Lactose 
Bile 
Blood 
450 to 500 
or 
30 to 34 gm. 
4 to 15 
(ratio to urea, 
1 :40) 
5 to 15 
8 to 15 
0.5 to 2 
0.015 
0.07 to 0.05 
Traces 
Traces. 
Traces. 
None 
None. 
None 
None or trace. 
None 
None 
None 
Increased after much meat, 
in fevers, diabetes mel- 
litus, copious drinking of 
water or alcohol, conges- 
tion of liver. 
Diminished in abstinence 
from meat, rest, hepatic 
abscess, nephritis, chronic 
wasting diseases. 
Increased in leukocy themia, 
pernicious anemia, gout, 
rheumatism, deficient oxi- 
dation ; organic diseases 
of heart, lungs, liver, or 
skin; after acute fevers 
and excessive meat diet. 
Diminished in vegetable 
diet, gout, before attack, 
chronic renal disease, out- 
door exercise. 
Increased with vegetable 
diet, after taking ben- 
zoates. 
Decreased in animal diet 
Increased in meat diet, 
and increased nitrogenous 
metabolism. 
Decreased in vegetable 
diet, and milk diet. 
Increased in splenic dis- 
ease, meat diet, deficient 
oxidation. 
Decreased in vegetable diet. 
Increased in certain dis- 
eases of the intestines, 
causing constipation 
(ileus, etc), but has been 
observed to be increased 
also in certain cases of 
diarrhea. 
Increased with diseases at- 
tended by constipation 
and intestinal fermen- 
tation, and occasionally, 
also, in cases of diarrhea. 
After cholera, cancer of 
the liver and stomach, 
purulent peritonitis. 
Valuable diagnostic sign 
in typhoid fever and can- 
cer of the liver. 
Increased in diabetes mel- 
litus; conditions of in- 
creased proteid metab- 
olism, with deficient oxi- 
dation. 
Nephritis, pregnancy, pois- 
oning by certain sub- 
stances, cold baths, vio- 
lent exercise, rheumatism, 
infection, fevers, etc. 
Presence not clearly diag- 
nostic. 
Presence not clearly diag- 
nostic. 
Glycosuria and diabetes 
mellitus. 
During lactation, a f t er 
weaning. 
Obstruction in bile-duct, 
structural hepatic dis- 
eases, malaria, pernicious 
anemia, yellow atrophy 
of liver, typhoid fever, 
and AsHs poisoning. 
Hemorrhages, giving hema- 
turia; hemoglobin in 
malaria, acute nephritis 
(sometimes). 
Inorganic. 
Constituents. 
Sulphuric acid. 
Phosphoric 
acid. 
Oxalic acid.... 
Phosphate of 
lime. 
Phosphate of 
magnesium. 
Chloride of 
sodium. 
Free acid (cal- 
culated as 
oxalic acid). 
Total inorganic 
salts. 
Potassium. 
Sodium. 
Calcium. 
Magnesium. 
Amount 
in Grains. 
23 to 38 
46 to 54 
0.3 
4 to 5 
7 to 11 
150 to 250 
Cl = 90 to 
150 
Na = 60 to 
90 
30 to 60 
200 to 380 
38 to 48 
140 to 180 
4 to 5 
2 to 3 
Alterations in Patho- 
logical Conditions. 
Having more or less the 
same source as urea, it 
will increase or diminish 
therewith. Occurs as 
sulphuric esters, and pre- 
formed. 
Increased in fevers, in 
nerve-exhaustion, disease 
of spinal cord, and in 
tubercle of the lung. In 
phosphatic diabetes the 
alkaline phosphates are 
greatly increased. 
Diminished in many men- 
tal diseases, e s p e c ia lly 
mania, in nephritis, and 
in chlorosis. 
Increased in catarrhal 
jaundice, and7in oxalic 
acid'diathesis, mental de- 
pression, and certain forms 
of dyspepsia. 
Increased in osteomalacia, 
rickets, scrofula, carcino- 
ma, long-continued sup- 
puration, organic disease 
of the spinal cord. 
Diminished in fevers. 
Increased in fevers at the 
onset, and with the re- 
absorption of dropsical 
fluids. 
Diminished during apy- 
rexia, dropsies, cholera, 
typhus, inflammations 
generally, and especially 
in the forming stage of 
pneumonia. 
Increased during the acme 
of acute febrile affections 
(on account, probably, of 
the diminished propor- 
tion of water present). 
Diminished in most dis- 
eases affecting the nutri- 
tion and leading to a 
deficiency thereof. 
URINE, EXAMINATION URINE, EXAMINATION 
URINE, EXAMINATION 
Organic 
Constituents. 
Amount 
in Grains. 
Alterations in Patho- 
logical Conditions. 
Pus.., 
Mucus 
None 
Present 
Suppuration. 
Increased in any irritation 
along the urinary tract, 
by uric acid, calcium 
oxalate, etc., catarrh of 
bladder, urethra, vagina. 
Usually increased in acute 
fevers. 
being used as a stopper, it is allowed to stand for 
10 minutes and then placed in a centrifuge the 
radius of which with tubes extended must be 6 3/4 
inches. The revolutions of the tubes should be 
at the rate of 1500 per minute and should last 3 
minutes. The amount of albumin is then read off 
in bulk percentage, 1 percent by bulk representing 
0.021 percent by weight of albumin. Each 
division of the tube corresponds to 1 percent, 
10 c.c. of urine being used and the divisions repre- 
senting tenths of a cubic centimeter. 
Clinical Significance.-It is stated by von 
Jaksch that the normal urine occasionally holds a 
variable quantity of albumin (serum-albumin 
globulin) as a temporary constituent, while at the 
same time the kidneys exhibit no alteration of 
structure; such is "cyclic albuminuria," which 
occurs during the day and disappears during the 
night. Many theories exist as to its exciting 
cause. 
When albumin persists in the urine, it must be 
considered pathologic, and its presence in the urine 
is looked upon as being indicative of inflammation 
or degenerative changes in the structure of the 
kidneys; in other words, of nephritis. However, 
albuminuria is too often taken as an evidence of 
nephritis. Careful microscopic study of the urine, 
together with skilful clinical examination, are 
necessary to insure a correct diagnosis. Certain 
associated minor signs of nephritis often neglected 
are: 
1. Auditory difficulties-ringing in the ears and 
deafness. Mounier has sought to bring the vertigo 
of Meniere's disease into this category. 
2. Numbness of the fingers or hand. 
3. Chilliness of legs and feet. 
4. Pruritus, likened to the sensation produced 
by a hair on the skin. 
5. Epistaxis, especially in the morning and 
beginning during sleep. 
6. The sign of the temporal artery. The arterial 
system is tense, the vessels are bent and hard, 
without there being arteriosclerosis: and this is 
shown especially well by the temporal artery. 
Each of these signs separately has little value; 
but collectively they are sometimes enough to form 
the diagnosis. 
The following is a table of differential diagnosis 
between functional and organic kidney-disease 
(Lane): 
Albumin.-The urine should always be filtered 
before being tested. 
Heller's Nitric Acid Test.-Place in a test-tube 
about 3 or 4 c.c. (45 to 60 minims) of pure nitric 
acid, and gently overlay with an equal amount 
of urine. If albumin is present, 
a cloudy ring of coagulated albu- 
min will appear at the junction of 
the two liquids. 
Frequently there will appear an 
opaque zone immediately above 
the point of contact of the fluids, 
which is often due to urea nitrate 
or to urates. If the urine is heated, 
this zone will disappear if due to 
these latter substances; whereas if 
due to albumin, the precipitate 
remains permanent. 
The Heat-and-acid Test.-In a 
test-tube place from 6 to 8 c.c. 
(90 to 120 minims) of urine, and 
boil. If albumin is present, a pre- 
cipitate appears, insoluble in a few 
drops of nitric or acetic acid. 
Earthy phosphates are also pre- 
cipitated from the urine by boiling, 
but these dissolve on the addition 
of nitric or acetic acid. 
Picric Acid.-In a test-tube place 
from 4 to 5 c.c. of urine, and overlay 
with a saturated watery solution of 
picric acid; if albumin is present, a 
deposit, which is insoluble on boil- 
ing, forms at the line of junction. 
Quantitative Determination of 
Albumin.-The albuminometer (a 
standard graduated glass tube) is 
filled with acidified urine to U, and 
the Esbach reagent added to R. 
This reagent consists of a solution 
of 10 grams of picric acid and 20 
grams of citric acid in 1 liter of 
distilled water. After closing the 
tube with a rubber stopper it is in- 
verted several times to mix the contents thoroughly 
and then placed for 24 hours in a test-tube rack. 
Then the amount of albumin is noted. The num- 
ber of grams of albumin in a liter of urine is rep- 
resented by the graduations on the tube. 
Purdy's Centrifugal Method.-To 10 c.c. of the 
urine in a centrifuge tube 3 c.c. of a 10 percent 
solution of potassium ferrocyanid and 2 c.c. of 50 
percent acetic acid are added. After inverting the 
tube to mix the contents thoroughly, the thumb 
Functional. 
Albumin may be pres- 
ent at infrequent in- 
tervals, and may vary 
in amount from a 
plain trace to 10 to 20 
grains in 24 hours. 
Albumin not found 
when patient is kept 
absolutely quiet, and 
rarely found in urine 
passed immediately 
on rising in the morn- 
ing. 
Organic. 
Albumin is usually per- 
sistent, though not 
always abundant. 
It may be intermittent 
and still be organic. 
Esbach's Albu- 
min ometer. URINE, EXAMINATION 
URINE, EXAMINATION 
Functional. 
If dropsy is present, it is 
dependent on insuffi- 
cient activity of the 
circulation, rather 
than on a tardy elim- 
ination of the fluids 
by the kidneys. A 
very careful examina- 
tion of the heart and 
larger vessels is im- 
perative. 
The quantity of urine 
passed in 24 hours 
(unless the use of 
mineral water, beer, 
etc., is frequently in- 
dulged in) will not 
vary greatly from 3 
pints. 
The day urine should 
exceed the night by 
double or more its 
bulk. 
The specific g r a vi t y 
should be between 
1015 and 1025, when 
taken from a sample 
of 24 hours' mixed 
urine. 
The urea is not dimin- 
ished for 24 hours. 
There is no complica- 
tion of acute diseases: 
viz., scarlatina, diph- 
theria, true gout, or 
retinal change. 
No pus or blood appears 
in the urine. 
No tube-casts are found. 
Patient is under 40 
years of age. 
Organic. 
Dropsy may or may not 
be present. 
The quantity of urine 
for 24 hours is usually 
decreased, though in 
many cases it is great- 
ly increased. 
The night urine fre- 
quently equals and 
sometimes ex c e e d s 
that of the day in 
bulk. 
The specific gravity 
(from a sample of 24 
hours' mixed urine) is 
usually above 1020, 
though it rarely gets 
above 1030. In those 
cases where the quan- 
tity of urine is greatly 
increased, the specific 
gravity is correspond- 
ingly decreased, occa- 
sionally falling as low 
as 1005. 
The urea is diminished 
for 24 hours. 
There may be complicat- 
ing diseases, as scar- 
latina, diphtheria, etc. 
There may be both pus 
and blood in the urine. 
Usually casts of urinary 
tubules are found. 
If patient is over 40 
years of age, the prog- 
nosis must be par- 
ticularly guarded. 
Cu2(OH)2 (Trommer's). In these two tests albu- 
min must first be removed. 
Fehling's Qualitative Test.-Fehling's solution 
deteriorates with age, and it is therefore desirable 
to keep the copper solution and the alkaline solu- 
tion separate. 
The two solutions may be prepared and the test 
made in the following manner (Greene): Solution 
A.-Dissolve 34.64 grams of pure, dry, powdered 
copper sulphate in 200 c.c. of warm distilled water 
and add distilled water to make 500 c.c. of the 
light blue solution. Solution B.-Dissolve in 300 
c.c. of hot water 180 grams of Rochelle salt. Fil- 
ter. Add of pure caustic soda, 70 grams. Cool, 
and add distilled water enough to make 500 c.c. of 
a colorless solution. Keep in a dark place. 
Pour into a test tube one finger's breadth of each 
of the stock solutions which when mixed should 
form a deep blue solution. 
Heat test solution to boiling-point, add at once 
20 to 30 drops of the suspected urine and boil no 
longer, but in the absence of a reaction set aside 
for from 5 to 30 minutes, and try the polariscopic 
and fermentation tests, a positive reaction proves 
nothing but the presence of a reducing agent 
unless the ultimate precipitate is red, not yellow 
or green. 
Objections to Fehling's Solution.-Fehling's 
solution as ordinarily prepared is open to serious 
objections: (a) It is unstable, (b) An excess of 
glucose obscures the terminal reaction by becom- 
ing caramelized if boiling is prolonged, (c) It 
cannot be directly applied to ammoniacal urine 
unless such be especially prepared, (d) A large 
number of substances may reduce its cupric oxid. 
Such are glycuronic and glycosuric acid, alkapton 
creatinin, uric acid, and various drugs, such as 
benzoic acid, chloroform, chloral, glycerin, the 
salicylates, turpentine, etc. Hence, if one uses 
Fehling's solution for qualitative work, he must 
bear in mind that it is more valuable as a negative 
than as a positive test. A urine that does not 
reduce Fehling's solution is free from glucose, 
but reduction does not conclusively establish its 
presence. 
Trommer's Qualitative Test.-To about 6 c.c. 
(11/2 drams) of the urine add about one-fourth 
its volume of sodium or potassium hydroxid solu- 
tion. Then add, drop by drop, a solution of 
cupric sulphate (about 10 percent solution) and 
agitate the liquid until the bluish-white precipi- 
tate of cupric hydroxid, Cu(OH)2, ceases to be 
dissolved and the liquid presents a slightly tur- 
bid or opaque appearance. Heat the liquid, and if 
glucose is present, the cupric oxid, CuO2, will be 
reduced to red or brownish-red cuprous oxid, 
Cu2O, or to yellow cuprous hydroxid, Cu2(OH)2. 
Haines' Test.-A much simpler test is Haines' 
modification of Trommer's test. This test has the 
advantage of making use of a solution that remains 
stable almost indefinitely. This solution consists 
of pure copper sulphate, 30 grains, distilled 
water, 1 ounce; when a perfect solution is made 
pure glycerin, 1/2 ounce, is added; then after 
thorough mixing, 5 ounces of liquor potassae are 
added. Of this solution 1 to 2 c.c. are gently 
Sugar (Glucose, Dextrose).-When the specific 
gravity of the urine is above 1030, it should be 
examined for glucose. 
Moore's test with sodium or potassium hydroxid, 
Boettger's bismuth test, and Johnson's picric acid 
test are all subject to fallacious results. 
Those tests which are recommended are Feh- 
ling's and Trommer's, which depend upon the 
reduction of cupric oxid, CuO2, in alkaline solution 
by glucose to red cuprous oxid, Cu2O (Fehling's 
and Trommer's) or to yellow cuprous hydroxid, URINE, EXAMINATION 
URINE, EXAMINATION 
boiled in a test-tube. Then 6 to 8 drops of the 
urine are added and the upper part of the solution 
is boiled gently for a second or two only. Pres- 
ence of sugar is indicated by the formation of a 
yellow or yellowish-red precipitate. 
Fermentation Test.-This test, which depends 
upon the production of carbon dioxide from 
glucose by the action of yeast, is best applied by 
means of an Einhorn fermentation tube so gradu- 
ated that the amount of carbon dioxid is read off 
in terms of percent of glucose. The urine must 
therefore be diluted so as to contain less than 1 
percent of -glucose, the result being multiplied by 
the dilution. To the acidified urine is added a 
piece of compressed yeast the size of a pea and 
the mixture shaken and 
poured in the tube with- 
out introduction of air 
bubbles. Controls are 
also made. The tubes 
are placed over night in 
the incubator at 37° C. 
The percentage of sugar 
is then read off from the 
small figures the larger 
representing the cubic 
centimeters of gas. 
The polariscope is also 
used to estimate the per- 
centage of glucose in the 
urine. 
Clinical Significance.- 
When found in the urine, 
glucose gives rise to what 
is called glycosuria, or 
diabetic urine. While it 
may be true that at times 
normal urine may contain 
a trace of glucose, yet 
from a clinical standpoint 
its occurrence and detec- 
tion by the ordinary tests when accompanied 
by polyuria, should be looked upon as pathologic, 
and as indicative of diabetes. Glycosuria is also 
found in such conditions as cholera, intermittent 
fever, cerebrospinal meningitis, and in certain dis- 
eases of the heart, lungs, and liver, and especially 
in those diseases that have their seat in the fourth 
ventricle of the brain. 
Indican.-Indoxyl potassium sulphate is an 
oxidation product of indol in the feces. Its 
method of formation is thought to be as follows: 
Indol in the intestines upon oxidation yields 
indoxyl, after which it combines in the liver with 
sulphuric acid and is eliminated as indoxyl potas- 
sium sulphate, or indican. 
Test (Jaffe's).-To a small quantity of urine 
(4 c.c.) in a test-tube add an equal quantity of 
pure hydrochloric acid, and subsequently one drop 
of a saturated aqueous solution of sodium or cal- 
cium hypochlorite; agitate thoroughly; now add 
about one-fourth the volume of chloroform and 
shake; within a few moments the indican is decom- 
posed into indigo-blue, which is dissolved out by 
the chloroform. 
The hypochlorite solution may be easily pre- 
pared by adding 2 or 3 ounces of the commercial 
chlorid of lime to 8 ounces of water. It should be 
allowed to stand over a day or two, being shaken 
frequently, and, finally, filtered under a well-fit- 
ting cover. It should be freshly prepared every 
four weeks. The hypochlorite solution may also 
be composed of a saturated aqueous solution of 
sodium hypochlorite. Like the solution prepared 
from lime, it quickly deteriorates. 
Clinical Significance.-At one time indican was 
thought to represent the amount of putrefaction 
occurring within the intestines, but this is not the 
case. In typhoid fever it is often absent. Some 
have thought that it is increased in wasting dis- 
eases and conditions in which the hydrochloric 
acid in the stomach is decreased, as in gastro- 
intestinal catarrh. It is said to be increased after 
a meat diet and in obstruction of the bowels, but 
this does not invariably hold true. 
Peptone. Ralfe's Test.-Gently overlay 4 c.c. 
(1 dram) of Fehling's solution with a small bulk of 
urine. If peptone is present, a rose-colored halo 
will develop immediately above the zone of phos- 
phates that frequently occurs at the point of con- 
tact of the two liquids. 
Clinical Significance.-Peptone frequently occurs 
in typhoid fever, scarlet fever, miliary tuberculosis, 
scrofulous pneumonia, jaundice, and cancer of the 
liver. 
Propeptone.-To a small quantity of urine in a 
test-tube add a few drops of nitric acid, which 
precipitates propeptones. Now heat, and the 
solution assumes a yellow color, which precipitates 
on cooling. It has the same clinical significance 
as peptone. 
Acetone.-In normal urine traces of acetone are 
found that may be called physiologic. 
Legal's Test.-To 3 or 4 c.c. (1 dram) of urine in 
a test-tube add enough solution of soda or potash 
to render it alkaline. To this solution then add a 
few drops of a freshly prepared saturated aqueous 
solution of sodium nitroprussid, and if acetone is 
present, a purple or violet-red color will be formed 
on the addition of chemically pure acetic acid. 
This test, however, is not distinctive for acetone 
as it is given by diacetic acid, alcohol and acetic 
aldehyd. 
Trommer's Test.-To 10 c.c. urine strongly 
alkalinized with potassium hydrate 10 to 12 drops 
of a 10 percent solution of salicylaldehyd in ab- 
solute alcohol are added and the mixture is 
heated to about 70° 0. If acetone is present 
the fluid changes color and becomes red upon 
standing. If absent, the color is unchanged. 
This last is very delicate and distinctive for 
acetone. 
Clinical Significance.-In certain instances ace- 
tone precedes the occurrence of diacetic acid in 
cases of diabetes, and its presence is always con- 
sidered an unfavorable symptom. It is also said 
to occur in the urine as the result of cancer and of 
cerebral disease. See Acetonuria. 
Diacetic Acid.-To urine freshly voided add a 
few drops of a strong aqueous solution of chlorid 
of iron. If a precipitate occurs, the mixture should 
be filtered. Heat the filtrate to boiling, and to a 
Einhorn's Saccharometer. URINE, EXAMINATION 
URINE, EXAMINATION 
small quantity again add the solution of ferric 
chlorid. If a red color is produced, add sulphuric 
acid and extract with ether by distillation. 
Arnold's Test modified by Lipliawsky is more 
satisfactory than the above. Two reagents are 
used: (1) 1 gram of paraamidoacetophenon, 100 
c.c. of distilled water, 2 c.c. concentrated hydro- 
chloric acid; (2) 1 percent sodium nitrite solution. 
To 6 c.c. of solution 1 and 3 c.c. of solution 2 
are added an equal volume of urine and 1 drop of 
ammonia. When shaken, the mixture becomes 
brick-red in color. Ten drops to 2 c.c. of this 
mixture, depending on the probable percentage 
of diacetic acid in the urine, are treated with 15 
to 20 c.c. of concentrated hydrochloric acid, 3 c.c. 
chloroform and 2 to 3 drops of ferric chlorid solu- 
tion. In the presence of diacetic acid the color of 
the chloroform changes to violet; if no trace is 
present the color is yellow or pale red. This test 
is very delicate and is not given by acetone in 
oxybutyric acid. 
Clinical Significance.-Diacetic acid is never 
found in normal urine, and when it occurs in dia- 
betes, the disease usually terminates fatally. In 
this condition it is spoken of as diabetic diaceturia. 
It may occur in certain febrile diseases, as typhoid 
fever, pneumonia, phthisis, pleurisy, and pericar- 
ditis, and in acute exanthematous diseases. See 
Acidosis. 
Coloring-matters (Bile). Gmelin's Test.-To a 
few drops of urine placed on a marble or porcelain 
slab add a few drops of impure nitric acid (or of 
nitric acid containing a few drops of nitrous acid), 
when a play of colors will be produced, such as 
green, violet, red, and yellow. The colors are best 
developed by placing the urine and acid a short 
distance apart and gradually bringing them 
together. This test may also be demonstrated 
in a test-tube by overlaying the acid with the 
urine. 
Clinical Significance.-Bihary pigment is nearly 
always present in the urine in cases of cholelithiasis 
and in the acute stage of catarrhal jaundice. 
Urea.-Different forms of ureameters are pre- 
ferred by authors. However, the principle upon 
which the more reliable appliances are constructed 
depends upon the decomposition of the urea in the 
urine when brought into contact with a solution 
of sodium hypobromite or hypochlorite with the 
evolution of nitrogen. 
Many forms of ureameters are too complicated, 
and cannot|be used by the general practitioner. 
Simpler forms, while not so delicate, are more 
frequently employed, and only vary within a few 
grains of the correct amount of urea. Albumin 
should always be removed before estimating for 
urea. 
Estimation of Urea by Doremus' Apparatus.- 
The sample of urine must be selected from the 
amount passed within 24 hours. 
To employ this method the following solutions 
are required, and must be freshly prepared. 
Bromin Solution. 
Bromin, 1 c.c. 
Sodium hydrate solution (as above), 25 c.c. 
Fill the upright graduated tube of the apparatus 
with the hypobromite solution as thus prepared to 
the mark .03, and add enough water to about half 
fill the bulb; mix thoroughly. Tilt the instrument 
forward, and by means of the pipet, pushed well 
into the head of the upright tube, slowly add 1 
c.c. of urine. After about 15 or 20 minutes read 
off the volume of gas, which gives the percentage 
of urea in 1 c.c. of urine. To determine the total 
amount of urea, multiply this percentage by the 
number of cubic centimeters of urine passed within 
the 24 hours. 
Ureameter of Doremus. 
Frequently the percentage of urea is so great 
that the volume of nitrogen presses the hypo- 
bromite solution below the .03 mark. When this 
is the case, dilute the urine with an equal amount 
of water and proceed as before. Multiply the 
percentage obtained by 2, which gives the per- 
centage of urea in the specimen of urine. 
Clinical Significance.-The normal quantity of 
urea within the 24 hours fluctuates greatly. From 
308 to 617 grains, or 1.5 to 2.5 percent, is the 
normal amount as stated by Tyson. In midwinter 
the urea may fall to 130 or 140 grains in those who 
lead sedentary lives. Urea is the chief organic 
constituent of the urine, and through its determi- 
nation furnishes an index to the rapidity of meta- 
bolic changes taking place within the body. How- 
ever, this change is not the only governing factor, 
since the quantity of urea depends also upon the 
amount of nitrogenous food ingested. The urea 
is increased (1) in diabetes mellitus; (2) by the use 
of nitrogenous foods; (3) after copious ingestion of 
water; (4) in acute febrile diseases; (5) in dyspepsia; 
(6) in nervousness. The urea is decreased (1) 
after prolonged rest; (2) by the use of vegetable 
foods; (3) by starvation; (4) by the excessive use 
of tea or coffee; (5) in nephritis. Muscular exercise 
has but little effect upon the excretion of urea. 
Alkaline Hypobromite Solution. 
Dissolve 100 gm. of sodium hydrate in 250 c.c. of 
water and allow to cool. URINE, EXAMINATION 
Uric acid exists in the urine for the most part 
in the form of soluble urates of sodium, potassium, 
and ammonium. 
Amount.-The amount of uric acid excreted 
daily by a healthy man ranges from 7 to 10 grains. 
Uric acid is soluble with difficulty in water 
(in 18,000 parts of cold and 15,000 parts of hot 
water), and is insoluble in alcohol and ether. 
In the urine it exists for the most part in the 
form of acid urates of sodium, and potassium. 
It is frequently found as a sediment in urine, 
having the color of cayenne pepper granules. 
Estimation of Uric Acid.-Probably the best and 
most accurate method for the estimation of uric 
acid by the general practitioner is that known 
as the Hopkins' method, which has been modified 
by Maisch as follows: To 100 c.c. (3 1/3 ounces) 
of urine add 30 gm. (1 ounce) of ammonium 
chlorid (or until saturated), and then add 5 c.c. 
(75 minims) of water of ammonia; allow the mix- 
ture to stand for from 15 minutes to half an 
hour and then filter. The flask in which the pre- 
cipitation is to be carried out is thoroughly washed 
with a saturated aqueous solution of ammonium 
chlorid and poured upon the filter, and is subse- 
quently washed several times with the saturated 
aqueous ammonium chlorid solution. The filter 
is then pushed through and the precipitate is trans- 
ferred to a beaker (of 6 to 8 ounces capacity) 
with hot water by means of a Spritz bottle; to 
this fluid is then added 1 to 2 c.c. (15 to 30 
minims) of pure hydrochloric acid, and the liquid 
is evaporated to 20 or 15 c.c. (1/2 of an ounce), 
when it is allowed to stand for 1 hour, or until 
cool. 
The precipitated uric acid is then collected upon 
a filter-paper, washed several times with water, 
and finally the filter is punched through and the 
uric acid is transferred to a porcelain capsule or a 
watch-glass with alcohol by means of a Spritz bot- 
tle, dried, and after removal of the small particles 
of filter-paper that appear on the top of the pre- 
cipitate, it is weighed. The product obtained 
is a reddish-brown amorphous powder which 
under the microscope is crystalline and light 
yellow or reddish-yellow in color. 
Clinical Significance.-When uric acid is not 
eliminated by the kidneys, it becomes stored up 
in the body and gives rise to what is known as the 
uric or "lithic" acid diathesis. Owing to the 
fact of its insolubility, uric acid is supposed 
by some to be deposited in the tissues, such as the 
serous membranes, giving rise to joint pains. 
By others its failure of elimination is supposed 
to give rise to headache, hemicrania, neuralgia, 
despondency, lumbago, and rheumatism. 
It is stated that uric acid and urea are elimin- 
ated in the urine in the relative proportion of 1 part 
of the former to 33 parts of the latter. This 
relation must, however, be accepted as subject to 
wide variations, depending upon such factors as 
the amount of exercise, the variety of food and 
drink, and the season of the year. 
While it was formerly held that uric acid has 
its origin for the most part in nitrogenous elements 
taken as food, the more recent opinion is that it 
URINE, EXAMINATION 
arises in the system from the disintegration of the 
leukocytes and nuclein. 
Uric acid is diminished in diseases interfering 
with the process of elimination, such as nephritis, 
and in diabetes, in chronic rheumatism, before 
paroxysms of gout, and in chlorosis. It is in- 
creased in leukemia, in indigestion, after attacks of 
gout, in acute fevers, in functional diseases, and 
in heart- and lung-diseases in which there is much 
dyspnea. Physiologically, it may be said to be 
increased or diminished pari passu with urea. 
Various Ingredients (Mucin, Fibrin), etc.- 
The importance of these ingredients in the urine 
has not been finally settled. 
Ehrlich's Diazo Reaction.-See Typhoid Fever. 
Microscopic Examination. 
The miscroscopic examination of urine deter- 
mines the presence or absence of (1) casts, (2) 
spermatozoa, (3) blood, (4) mucus or pus, (5) 
epithelium, (6) fungi, (7) uric acid, (8) urates of 
sodium and ammonium, (9) calcium oxalate, (10) 
calcium carbonate and 
sulphate, (11) triple 
phosphates, (12) leu- 
cin and tyrosin, (13) 
cystin. 
To examine the 
urine microscopically 
the sediment is first 
obtained, either > by 
means of the centri- 
fuge or after the urine 
has stood for a period 
of from 12 to 24 hours. 
The urine may be pre- 
served for a consider- 
able length of time by 
the addition of a small 
quantity (from 5 grains 
to 1 dram) of chloral 
hydrate, or by adding 
1 part of carbolic acid 
to 100 parts of urine 
or 1 part of mercuric 
chlorid to 3000 parts 
of urine. 
Casts.-These bodies 
are molds of the urin- 
iferous tubules, and 
are composed of the coagulable constituents of the 
blood that are pressed out of the blood-vessels into 
the tubules, and are afterwards excreted in the 
urine. This process forms the hyaline or granular 
cast. In some instances the cast also involves 
the epithelial cells of the tubule, which become 
detached, giving rise to an epithelial cast. Blood 
may also be entangled in the coagulable particles. 
Usually, this process is accompanied by the oc- 
currence of albumin in the urine, but casts may 
be present in urine without albuminuria. 
Tube casts vary in size, shape, and appearance. 
Their length ranges up to 200/z or more; their 
diameter from 4« to 40/z. They are usually 
straight, but may be curved, twisted, convoluted, 
or branched. 
Centrifuge. URINE, EXAMINATION 
URINE, EXAMINATION 
Varieties.-Blood casts are those composed of 
coagulated blood with corpuscles embedded. 
They show that the hematuria originates in the 
secreting structure of the kidney. 
leukocytes; indicative of involvement of the 
interstitial kidney substance. 
Seminal casts are molds of the seminal tubules 
found in the urine, and are recognized by the 
presence of spermatozoids. 
Waxy casts are those that give the amyloid 
reaction; they are large and yellowish in appear- 
ance, and are indicative of serious nephritis. 
a. Blood cast and hyaline cast carrying blood-cells, b. 
Leukocyte or pus-cast. c. Hyaline cast carrying renal cells. 
Epithelial casts.-(Greene.) 
Epithelial casts are those composed of plastic 
matter with cells embedded and denoting desquam- 
ative inflammation. 
a, a, a. Round epithelium from bladder, b, b, b, b. Colum- 
nar epithelium from ureters and urethra, c1, c1, c1. Columnar 
and squamous epithelium from deeper layers of epithelium 
of bladder, c2. Squamous epithelium from superficial layers 
of epithelium of vagina.-(Tyson.) 
Clinical Significance of the Different Varieties of 
Casts. 
Granular casts light and dark, coarse and finely granular. 
(Greene.) 
Acute Paren- 
chymatous 
Nephritis. 
Chronic Parenchy- 
matous Nephritis. 
Chronic Intersti- 
tial Nephritis. 
Only a few 
casts present. 
Many casts seen. 
Few casts present. 
Blood casts, epi- 
In early stages large 
Large and small hya- 
thelial casts, 
hyaline and dark 
line casts, waxy 
leukocytes. 
granular casts. In 
later stages epithe- 
lial, large and small 
granular casts, hya- 
line casts, and com- 
pound granular 
cells. 
casts, fatty casts, 
oil droplets. 
During conva- 
In acute exacerba- 
In acute exacerba- 
lescence fatty 
tions, on account of 
tions on account of 
casts may be 
the inflammatory 
the inflammatory 
present. 
processes, there 
may be present epi- 
thelial casts and 
process, there may 
be present all varie- 
ties of casts, espe- 
many leukocytes. 
cially large and 
small granular casts. 
Fatty casts are those containing free fat globules 
in the coagulated matter, indicating fatty degener- 
ation in a chronic nephritis. 
Granular casts are those containing finely 
divided, granular debris, either in scattered 
a. Waxy casts, b. Fatty or fat-bearing casts.-(Greene.) 
During most acute fevers hyaline casts are 
found. Cylindroids have no clinical significance. 
Epithelium.-When the renal epithelium is 
found in the urine, it generally denotes a grave 
form of kidney-disease. It may be recognized 
by the large, oval nuclei. An excessive amount 
masses or completely filling the casts. They are 
usually found in cases of contracted kidney. 
Hyaline casts are transparent, soft, delicate 
casts, also called mucous casts. 
Pus casts are those that contain degenerated URINE, EXAMINATION 
URINE, EXAMINATION 
a. Leukocyte (for comparison), b. Renal cells, c. Superficial pelvic cells. 
d. Deep pelvic cells, e. Cells from calices, f. Cells from ureter, g, g, g, g, g. 
Squamous epithelium from the bladder, h, h. Neck-of-bladder cells, i. Epi- 
thelium from prostatic urethra, k. Urethral cells. I, I. Scaly epithelium. 
m, m'. Cells from seminal passages, n. Compound granule cells, o. Fatty 
renal cell.-(Ogden.) 
Epithelium from Different Areas of the Urinary Tract. 
of epithelial cells from the bladder, in combination 
with pus, denotes cystitis. See also Hema- 
turia. 
Bacteria are frequently found in the urine. 
Tuberculosis of the urinary tract is often diagnos- 
ticated by discovery of the 
tubercle bacilli in the urine. 
To examine the urine for tuber- 
cle bacilli, the sediment must 
be thoroughly centrifuged, 
and then examined in the 
same way that sputum is (see 
Tuberculosis); but a small 
amount of egg albumin is 
added to the specimen before 
it is placed on the slide or 
coverslip. 
Yeast fungi are found in 
nearly all specimens of urine after they have been 
exposed to the air. 
Spermatozoa and Associated Substances in Urinary 
Deposits. 
a,a,a,a. Spermatozoa. c,c. Spermatozoa, tail out of focus. 
d,d,d. Amyloid corpuscles, e. Prostatic cast. g. Crystals. 
h. Lecithin-granule cells. k,k,k. Epithelium.-(.Greene.) 
Tubercle Bacilli in 
Urine. (Greene.) 
Observe tendency to 
form groups. 
Spermatozoa may be found in the urine. See 
Semen. 
Calculi.-See Urinary Calculi. 
Urinary Sediments.-See the following table. 
URINARY SEDIMENTS, TABLE OF. 
Variety. 
Gross Appear- 
ances and 
Characters. 
Microscopic 
Features. 
Tests. 
Significance. 
Illustrations. 
{After Tyson, Greene, Casselman 
Landois, Beale, Jakob and 
von Jaksch.) 
Blood 
A flocculent, 
red deposit. 
Blood-corpuscles. 
Equal parts of 
tincture gua- 
iac and ma- 
ture oil tur- 
pentine or 
ozonic ether 
cause green 
line at junc- 
t i q n with 
urine. 
Disease of 
kidney, bladder, 
or urethra. 
" ® * °° * 
% ® c .A 
• » ® * a 
l»®® URINE, EXAMINATION 
URINE, EXAMINATION 
URINARY SEDIMENTS, TABLE OF. 
Variety. 
Gross Appear- 
ances and 
Characters. 
Microscopic 
Features. 
Tests. 
Significance. 
Illustrations. 
{After Tyson, Greene, Casselman, 
Landois, Beale, and vonjaksch.) 
Calcium carbo- 
nate. 
Whitish sedi- 
ment (rare); 
urine a 1 k a- 
line. 
Amorphous 
g r a n u 1 e s; 
small spheric or 
dumb-bell crys- 
tals. 
Soluble in 
acids with ef- 
fervescence. 
No special sig- 
nificance. 
/ co 
7 
Calcium oxalate. 
Cloudy, whit- 
ish, often 
highly re- 
fracting sedi- 
ment. 
Transparent, re- 
fracting o c t a- 
hedra. Some- 
times "dumb- 
bell" shaped. 
Soluble in min- 
eral acids, 
not in acetic. 
Vegetable diet, 
especially rhu- 
barb; oxaluria; 
often with uric 
acid in lithemia. 
A, -AA \ 
\ ex / 
\ 7 r / 
\ ° 1 S 
Calcium phos- 
phate. 
W h i t is h or 
y el 1 o w i s h 
sediment; 
urine feebly 
acid or alka- 
line. 
Amorphous gran- 
ules, or wedge- 
shaped crystals, 
separate or in 
roset-like clus- 
ters. 
Insoluble by 
heat; s o 1 u- 
ble in acetic 
or mineral 
acids. 
Phosph a turia; 
dyspepsia; alka- 
line fermenta- 
tion. 
7^' • / 
u ' D U nV 
Calcium sul- 
phate. 
Not distinct- 
ive; rare; 
urine acid. 
Elongated, trans- 
parent needles 
or tablets- 
Insoluble in 
ammonia or 
acids. 
No special sig- 
nificance. 
Cholesterin 
Not distinc- 
tive; very 
rare; urine 
alkaline. 
Large, transpar- 
ent plates, often 
superimpo s e d; 
one corner fre- 
quently defec- 
tive. 
The micro- 
scopic ap- 
pearances. 
Pyelitis, cystitis, 
etc. URINE, EXAMINATION 
URINE, EXAMINATION 
URINARY SEDIMENTS, TABLE OF 
Variety. 
Gross Appear- 
ances and 
Characters. 
Microscopic 
Features. 
Tests. 
Significance. 
Illustrations. 
{After^Tyson, Greene, Casselman, 
Landois, Hawk, Beale, and 
von Jaksch.) 
Cystin 
White or yel- 
lowish - gray 
deposit; 
rare; acid, 
neutral, or al- 
kaline urine. 
Six-sided plates, 
often superim- 
posed. 
Crystals burn 
on platinum 
with a bluish- 
green flame 
without 
melting ; 
if heated 
with caustic 
potash on sil- 
ver plate 
leave a per- 
manent, dark 
stain. 
Cystinuria may 
be an hereditary 
and insignifi- 
cant condition; 
or it may indi- 
cate the pres- 
ence of a cys- 
tin stone in the 
kidney. 
/ 
Hippuric acid.. 
Not distinc- 
tive; whitish 
deposit; 
urine acid. 
• 
Four-sided prisms 
with two or four 
beveled edges at 
the ends. 
Dissolved i n 
ammonia, 
but not in 
hydrochloric 
acid 
Diet of cran- 
berries and other 
vegetables; ad- 
ministration of 
benzoic acid; in 
diabetes. 
IK fl 
Indigo 
Amorphous 
fragments or 
concre t i o n s 
of blue color; 
urine alka- 
line or acid. 
Amorphous gran- 
ules, fine needles 
and crystals of 
of a blue color. 
The color is 
distinctive. 
In decomposing 
urine. 
V ® 
Leucin and 
tyrosin. 
Usually a bile- 
stained de- 
posit; often 
scanty; rare; 
urine acid. 
Leucin: Yellowish 
highly refracting 
spheres, c o n - 
taining radiat- 
ing lines. 
Tyrosin: "Nee- 
dles" arranged 
in "sheafs." 
Leucin: Heat- 
ing with pro- 
tonitrate of 
mercury in 
solution de- 
posits metal- 
lic mercury. 
Tyrosin: Crys- 
t a 1 s d i s- 
solved in hot 
water, and 
treated with 
mercuric ni- 
trate and ni- 
trate of po- 
tassium, giv- 
ing a red so- 
lution and 
red precipi- 
tate. 
Destruction of 
liver; especially 
acute yellow 
atrophy, and 
pho s p h o r u s- 
poisoning. 
r% W ® 
1 
1 
Jr 
Magnesium 
phosphate. 
Not distinctive; 
rare; urine 
concentrated, 
but feebly 
acid or alka- 
line. 
1 
Large, strongly 
refracting plates, 
in the shape of 
elongated rhom- 
bic tablets. 
Soluble in 
acetic acid, 
re-precipi- 
tated by car- 
bonate of so- 
dium. 
N o special sig- 
nificance. 
on $<& 
Mucin 
Cloudy tur- 
bidity or a 
viscid, gelat- 
; inous s e d i- 
ment. 
Epithelium and 
leukocytes, held 
inastringy, 
transparent 
mass. 
Acetic acid 
causes cloud- 
i n e s s or 
precipitate. 
Genito-uri n ar y 
catarrh, especi- 
ally cystitis. URINE, EXAMINATION 
URINE, EXAMINATION 
URINARY SEDIMENTS, TABLE OF. 
Variety. 
Gross Appear- 
ances and 
Characters. 
Microscopic 
Features. 
Tests. 
Significance. 
Illustrations. 
(After Tyson, Greene, Casselman, Lan- 
dois, Hawk, Beale, and vonJaksch.) 
f \ 
\ ^^0 1 
Phosp hates, 
Triple-Am- 
monio-mag- 
nesium phos- 
phate. 
Heavy, white 
deposit; 
urine feebly 
acid or alka- 
line. 
Triangular prisms 
with beveled 
edges- "coffin 
lids." Also 
feathery, star 
shapes, and 
other forms. 
Insoluble b y 
heat. Solu- 
ble in acetic 
o r mineral 
acids. 
Dyspepsia; alka- 
line fermenta- 
tion of urine; 
cystitis. 
Pus 
Compact, 
thick, viscid 
sediment; 
urine acid or 
alkaline. 
Degenerated leu- 
kocytes. 
The dark-red 
color of pus- 
c o r p u scles 
o n adding 
iodo - potas- 
sic-iodid so- 
lution. 
In acid urine, 
with uric acid 
and no mucus; 
pyelitis; or al- 
alkaline urine 
with triple 
phosphates; 
cystitis. 
®e 
® © © © 
sI 
Tyrosin 
See Leucin. 
Urates of sodi- 
um, ammoni- 
um, and po- 
tassium. 
(.The illustra- 
tion is of am- 
monium urate.) 
" Brick-dust" 
deposit, the 
color due to 
the color of 
the urine. 
Dissolved 
and cleared 
by heating. 
Urine acid; 
some times 
alkaline. 
Amorphous gran- 
ules. Ammo- 
nium urate ap- 
pears as spheric 
crystals sur- 
rounded by 
spicule s- 
"h e d g e-h o g 
crystals." 
Dissolved by 
heat or on 
adding acids. 
Lithemic and | 
rheumatic dia- 
thesis. Fever. 
Ammonium 
urate occurs 
when an acid 
urine is under- 
going alkaline 
fermentation. 
MY* 
5^ * ' * 
Uric acid 
Small grains, 
r e s e mbling 
red pepper; 
urine acid. 
Crystals of vari- 
ous shapes 
colored brown- 
ish-red by the 
u r i n ary pig- 
ments. The 
commonest form 
r e s e mbles a 
whetstone. 
The crystals 
dissolve in 
caustic pot- 
a s h. The 
murexid - test 
produces a 
purple color. 
Lithemic or rheu- 
matic diathesis. 
I "W $ j 
\ a J 
Xanthin 
Not distinc- 
tive; urine 
acid; very 
rare 
"Whetstone" 
crystals. 
Insoluble in 
acetic acid; 
soluble in 
ammonia. 
Xanthin-stone in 
the kidney. 
VW 
MW /YA 1 URINE, EXTRAVASATION 
URINE, EXTRAVASATION.-Extravasation of 
urine is commonly, though not always, the result 
of stricture, and is then due either to the dilated 
urethra behind a stricture ulcerating and giving 
way, or to a lacunar abscess bursting into the 
urethra. In either case the urine is forced by the 
contraction of the bladder into the surrounding 
cellular tissue. 
The urethra may give way (1) in front of the 
anterior layer, (2) between the two layers, or (3) 
behind the posterior layer of the triangular liga- 
ment. In the first and by far the most common 
situation it is the bulbous portion of the urethra 
that gives way. Here the urine is prevented from 
passing (1) backward into the pelvis by the 
anterior layer of the triangular ligament which is 
attached to the rami of the pubes and ischium and 
to the subpubic ligament; (2) downward into the 
ischiorectal fossa by the anterior layer of the 
triangular ligament continuous around the trans- 
verse perineal muscle with the deep layer of the 
superficial fascia of the perineum; (3) laterally, on 
to the thighs, by the deep layer of the superficial 
fascia of the perineum attached to the rami of the 
pubes and ischium. Hence it passes in the middle 
line into the cellular tissue of the scrotum and 
penis, and laterally on to the abdomen, where it is 
prevented from passing down the thigh by the 
deep layer of the superficial fascia of the groin 
(which is continuous with the deep layer of the 
superficial fascia of the perineum) which is at- 
tached along the line of Poupart's ligament. 
When the membranous portion of the urethra is 
ruptured, the urine is confined at first between the 
two layers of the triangular ligament, and if not 
released, will make its way (1) forward, through 
the anterior layer, and take the course given; or, 
rarely, (2) backward, through the posterior layer, 
and then, as when the urethra gives way behind 
the posterior layer, will make its way around the 
neck of the bladder, and finally induce a fatal 
result. Wherever the urine spreads it causes 
inflammation and sloughing. 
Symptoms.-The history of a case of extravasa- 
tion is not uncommonly as follows: A patient with 
a tight stricture is straining to pass water; he feels 
something give way, experiences a sensation of 
relief, and perhaps owing to the tension being 
removed by urine being forced into the cellular 
tissue, the superadded spasm for a time ceases, 
and a few ounces of urine are passed through the 
urethra. In half an hour or so a pricking or 
burning sensation is felt in the perineum, soon 
followed by pain, and by rapidly increasing 
swelling of the perineum, scrotum, and penis. 
If the urine is not let out by timely incisions, the 
swellng extends to the groin, and in some cases 
has been known to reach as high as the axilla. 
The skin now appears dusky or purplish-red and 
edematous, and gangrene and sloughing of the 
infiltrated tissues rapidly ensue. The absorption 
of the septic products gives rise to constitutional 
disturbance and to fever, which, though it may at 
first run high, soon assumes a low typhoid charac- 
ter, and the patient, especially if the subject of 
chronic kidney-disease, frequently sinks into a 
URINE, INCONTINENCE 
comatose state and dies. When the extravasation 
occurs between the two layers of the triangular 
ligament, it may remain localized, giving rise to a 
hard, circumscribed swelling in the perineum, 
which may slowly make its way toward the scro- 
tum; and, lastly, when the extravasation occurs 
behind the posterior layer of the triangular 
ligament, and the urine is extravasated into the 
pelvic cellular tissue, the symptoms resemble 
those of extraperi toneal rupture of the bladder 
(Walsham). 
Treatment.-A catheter should be passed into the 
bladder, or, when this is impossible, down to the 
stricture, and in either case a free incision, extend- 
ing into the urethra, should be made on the catheter, 
in the middle line of the perineum. Free incisions 
through the skin of the scrotum, penis, and groins- 
in fact, wherever the urine has penetrated-should 
likewise be made, to allow of its draining away, 
and the wounds should be rendered as far as 
possible aseptic by the free application of iodoform 
or other antiseptics. At the same time the 
patient's strength must be supported by fluid 
nourishment and stimulants; opium should be 
given, unless contraindicated on account of kidney- 
disease. 
URINE, INCONTINENCE (Enuresis).-Noc- 
turnal enuresis may occur in adults or in children. 
It is more common in boys than in girls. It rarely 
persists beyond puberty; if so, it is usually in- 
curable; such cases are most often met with in 
girls. Urination may occur once or several times 
during the night-most often during the first 
sound sleep-and again in the early morning. 
During the first months of life the urine is re- 
tained in the bladder for only a short time, but 
after the first year constant or very frequent 
micturition indicates some abnormality or disease, 
although it may be due to mere habit. Paralysis; 
malformation; the secretion of a large amount of 
urine, as in diabetes insipidus; hyperacid urine; 
calculus; cystitis; irritation of the penis, from 
adhesions to the glans penis, etc.; a tight prepuce 
or contracted meatus; worms or other rectal 
irritation; unduly profound sleep, from the semi- 
asphyxiated condition caused by enlarged tonsils 
or postnasal adenoids; dreams or gastric disturb- 
ance, from late or unwholesome meals, and 
masturbation-these are all causes. Ill health, 
conjoined with an unstable and easily excited mind, 
may give rise to enuresis. The condition has been 
known to subside in delicate children on the cor- 
rection of eye-strain. Renal calculus or pyelitis 
of tubercular origin may be possible causes. 
In adults enuresis may arise from an over- 
distended bladder, from which urine continually 
dribbles. This is nearly always the result of 
impacted urethral calculus, phimosis, hyper- 
trophied prostate, paralysis, or stricture. The 
use of a filiform bougie or a very finely calibered 
catheter on the first attempt to withdraw the 
urine will differentiate from incontinence, while 
the associated paralysis, if any, will confirm the 
diagnosis. 
Incontinence of urine in women may occur 
from injury to the neck of the bladder or to URINE, INCONTINENCE 
URINE, RETENTION 
the urethra, from the prolonged pressure of the 
child's head during labor, or from instruments, 
or the removal of stone. It may be nocturnal 
or daily. 
Treatment.-In the treatment of nocturnal 
incontinence of urine, apart from paralysis and 
irremediable malformations, the cause is to be 
looked for and all sources of irritation are to be 
removed. If due to phimosis, circumcision 
should be done; if to adhesions, these must 
be broken down; if the meatus is too small, dila- 
tation or meatotomy should be performed. The 
urine should be examined for overacidity and 
for evidence of cystitis, and these conditions 
should be corrected by the use of potassium 
citrate or of liquor potassae. If the diet is 
at fault, it should be corrected and irritating 
food should be forbidden. Worms must be 
removed by appropriate treatment. Late or 
undigestible meals are to be forbidden, and the 
habit of sleeping on the back is to be avoided. 
Too great weight of bedclothes is often provocative, 
and is to be remedied. 
The most serviceable drug, after alkaline diuret- 
ics, is belladonna, or its alkaloid, atropin. Bella- 
donna should be given in full and increasing doses 
(from 5 to 10 drops of the tincture 3 times daily; 
increase to from 10 to 20 drops in 12 hours) until 
physiologic results are obtained. Atropin is some- 
times effective when belladonna fails. Potassium 
bromid may be given alone or with bella- 
donna, while ergot, cantharides, potassium nitrate, 
camphor, and other drugs have been employed. 
In the incontinence of adults resulting from 
sudden movement or from excessive laughter, 
drop doses of the tincture of cantharides, 3 times 
daily, will do much to effect a cure, alkaline 
diuretics being employed at the same time. 
Punishment, by severe scoldings or whippings, is 
useless, and makes the sufferer sullen, and prob- 
ably augments the trouble. If enuresis results 
from habit, it may be necessary to administer 
diuretic waters for a long time. The habit of 
passing urine just before retiring, and of arising 
for the same purpose several times during the 
night, should be encouraged. 
The following prescriptions are useful: 
I|. Potassium citrate, 3 ss 
Spirit of nitrous ether, 3 vj 
Water, enough to make 3 j. 
Give a dessertspoonful every 4 hours in an 
equal quantity of water. 
1^. Arsenic trioxid, gr. 1/3 
Extract of nux vomica, gr. ij. 
Make into 20 pills. Give 1 pill 3 times daily 
after meals to a child of 8 or 10 years. 
When enuresis results from paralysis or from 
retention and distention of the bladder, the catheter 
is to be used. Asepsis must be strictly maintained, 
and the bladder washed out with a weak anti- 
septic fluid, such as boric acid solution or a solution 
of 1:10,000 of bichlorid of mercury, or of 1:100 
of phenol, when paralysis is responsible for the 
condition. In some incurable cases a urinal must 
be worn. 
URINE, RETENTION.-Retention of urine is 
either partial or complete. In the former condi- 
tion a certain amount of urine is never expelled, 
and the capacity of the bladder is proportionately 
diminished; in the latter it is distended until it can 
hold no more. 
Etiology.-Either the expulsive power of the 
bladder is defective or there is some obstruction to 
the exit of the urine; or both may happen. 
1. The former may arise from failure of the 
muscular power or of the nervous stimuli, or of 
both. Atony and peritonitis, spreading to the 
muscular coat, are instances of the first named 
cause; paralysis from disease or injury of the spinal 
cord or of the sacral nerves, hysteria, exhaustion 
(as in fevers), alcoholic excesses, shock, and, 
perhaps, belladonna poisoning, of the second. 
Railway accidents, operations around the rectum, 
such as ligation of piles, and injuries in the region 
of the pelvis are especially likely to cause it; but 
in old people, and in those in whom the wall of the 
bladder is already in a condition of partial atony, 
retention may follow the slightest accident, even 
a fall on the trochanter or the passage of a catheter. 
2. Obstruction to the flow of urine may be 
situated: 
(a) In the interior of the canal: impacted cal- 
culus, for example. 
(b) Outside the urethra: such as a string tied 
around the penis by a child to check nocturnal 
incontinence or the pressure of a gravid or dis- 
placed uterus. 
(c) In the wall itself. This is by far the most 
common. The affection may be permanent, as 
stricture or enlarged prostate; or temporary, as 
congestion and spasm. In most cases temporary 
and permanent causes act together. An impacted 
calculus, for instance, may occupy only a small 
part of the interior, but the spasmodic contraction 
that it causes prevents the passage of a drop of 
urine; a stricture which admits a No. 7 or No. 9 
French catheter may suddenly become closed in 
the same way, owing to alcoholic excesses or to 
exposure to cold; an enlarged prostate may have 
existed for years without serious inconvenience, 
until suddenly congestion sets in, and the mucous 
membrane becomes so swollen that the weakened 
muscular fiber gives way. 
Symptoms.-When retention has come on 
slowly, as from the gradual contraction of an 
organic stricture, there may be but little local 
pain and no constitutional disturbance, even 
though the bladder may be distended by many 
ounces of urine. When, however, it is produced 
suddenly, there is usually great pain, followed by 
severe constitutional symptoms-a small and fre- 
quent pulse, a dry and brown tongue, and per- 
haps delirium, symptoms probably due to the 
sudden check to secretion by the kidneys and to 
the stretching of the bladder. The bladder itself, 
unless greatly hypertrophied and contracted, 
rises out of the pelvis, and may be felt as a dis- 
tinct tumor, dull to percussion, and at times 
extending as high as the umbilicus, or, in extreme URINE, RETENTION 
URINE, SUPPRESSION 
cases, even to the ensiform cartilage. The patient, 
unless drunk, usually complains of inability to 
pass urine. When, however, the bladder has 
become gradually distended and urine is passively 
flowing away, he may complain of inability to 
hold his urine, and be quite unaware that the 
bladder is full, and may object to having a cath- 
eter passed until the condition has been explained. 
The presence of a swelling in the abdomen, and the 
flowing of urine through the catheter immediately 
after the patient has passed urine and believes 
that he has emptied his bladder, should serve for 
the diagnosis. In suppression of urine the blad- 
der is found empty on passing a catheter. 
Results of Retention.-If the bladder is soon 
relieved, no apparent harm may ensue. If 
neglected, however, the overdistention may lead 
to (1) atony of the muscular coat; (2) cystitis; (3) 
nephritis; (4) rupture of the urethra behind the 
obstruction; (5) rupture of the bladder itself 
(rarely); and (6) passive overflow of urine, the 
bladder remaining full. 
Treatment.-The distended bladder must be 
relieved, and if the distention is extreme and the 
symptoms urgent, at once. 
As a rule, the patient is to be kept warm and 
should lie on his back. The administration of a 
hot bath and an opiate, or of a few drops of chloro- 
form, may suffice, but usually resort must be had 
to instrumental aid. If success at passing an 
instrument into the bladder is not shortly obtained, 
it may be necessary to administer an anesthetic. 
In hysteric retention in women judicious indiffer- 
ence is best. After a safe interval the bladder 
should be relieved by the passage of a soft-rubber 
or gum catheter and withdrawing the urine. A 
hot hip-bath or cold water thrown suddenly over 
the back will often produce the desired effect. 
In cases of retention of urine in young children 
an enema thrown into the rectum will often so 
stimulate both the center for defecation and the 
genitospinal center for urination as to bring about 
micturition without catheterism-a proceeding 
always dangerous in young children, unless they 
have been anesthetized. When retention is due 
to cyst of the sinus pocularis the passage of an 
instrument will rupture the cyst and the infant 
will be relieved. 
When the cause of the retention is a stricture, 
it is well to try to pass first a soft catheter, then a 
hard catheter,' employing large sizes at first, 
although some surgeons advise the immediate use 
of the filiform bougie. It is advantageous to 
withdraw but half of the retained urine, withdraw- 
ing the remainder after waiting half an hour, and 
then washing out the bladder with hot boric acid 
solution. After withdrawal of the urine hot 
blankets should be wrapped around the patient, 
and a hot sand-bag may be placed against the 
perineum and a hot water-bag over the hypo- 
gastrium. A suppository of opium and bella- 
donna and tablets of salol and boric acid may be 
employed for several days subsequently. 
If failure ensues from the use of rubber or silk 
or hard catheters, filiform bougies are to be 
employed. This form of bougie acts as a capil- 
lary drain, and will empty the bladder in a few 
hours. It is, of course, to be allowed to remain 
in the bladder until this is accomplished. Succes- 
sively larger bougies are to be inserted alongside 
of the filiform for several days. No attempt is to 
be made to dilate the stricture forcibly until 
retention has ceased and inflammation has sub- 
sided. 
Aspiration and suprapubic or perineal cystot- 
omy must be resorted to when other means have 
failed. See Urethra (Stricture). 
In simple inflammation of the urethra the hot 
hip-bath, the use of suppositories of opium and 
belladonna, and the application of the hot sand- 
bag to the perineum and of the hot water-bag over 
the hypogastrium are means usually employed 
with success. A soft catheter is to be used if 
these measures fail, or if the symptoms are very 
urgent. 
In spasmodic stricture a metal catheter of good 
size should be held firmly against the spasmodic 
area a sufficient length of time to cause the stric- 
ture to relax. 
The occluded meatus of a new-born child may 
be incised with a tenotome or may be dilated. 
In complete phimosis the prepuce is to be slit up. 
A urethral stone may be removed by the urethral 
forceps or may be pushed in or out. When fecal 
impaction causes retention, the feces must be 
removed by enema, by the hand, or with a scoop. 
When prostatic hypertrophy is causative, a fili- 
form bougie is first passed, and over a catheter. 
A silver instrument with a large curve is some- 
times employed. A soft catheter is to be em- 
ployed when expulsive defect exists. See Pros- 
tate (Diseases). 
The administration of laxatives, maintenance 
of the free action of the skin, warmth, and confine- 
ment to bed are general means of treatment com- 
monly employed, while the use of such drugs as 
salol, boric acid, and quinin is advised to render 
the urine antiseptic. It is, of course, understood 
that asepsis and antisepsis are important in the 
use of instruments. 
Aspiration is to be employed, under antiseptic 
precautions, when other means fail. The trocar 
or aspirator needle should be passed in the median 
line just over the pubes, its course being down- 
ward and backward. The puncture must be 
antiseptically dressed: e. g., with iodoform and 
collodion. See Bladder (Paracentesis). 
When rupture of the urethra has taken place 
and retention of urine ensues, perineal incision is 
advised, but otherwise it is not now resorted to. 
It must always be borne in mind that the horizon- 
tal position is to be maintained when passing the 
catheter, as this position lessens shock. See 
Urethra (Injuries) Urine (Extravasation), 
Urine (Suppression). 
URINE, SUPPRESSION.-Suppression of urine 
is the term applied to the nonsecretion of urine by 
the kidneys, and it must not be confounded with 
retention of urine, in which the urine is secreted as 
usual, but its passage from the bladder is obstructed. 
In the former condition the bladder is empty; 
in the latter, distended. Suppression of urine may UROTROPIN 
URTICARIA 
be due to obstruction of the ureter by a calculus, 
acute nephritis, or sudden shock. The usual 
causes of such shock are genitourinary operations. 
Suppression of urine is also caused by acute 
poisoning by phosphorus, lead, turpentine, can- 
tharides, etc. It is seen in the collapse stages of 
cholera and yellow fever and in hysteria. If sup- 
pression of urine is not relieved, coma, convulsions, 
and death from uremia quickly ensue. 
Treatment.-Dry or wet cupping of the loins, 
hot vapor baths, free purging, as by elaterium or 
croton oil, the administration of diuretics, injec- 
tions of pilocarpin, and hot enemata by the rectum 
are, at times, successful in relieving the congested 
kidney. Large, hot irrigations of normal salt 
solution, with the double current rectal tubes, or 
infusion of saline fluids in the tissues or veins, may 
be tried. See Nephritis, Urine (Retention). 
UROTROPIN (Hexamethylenamin). C6H12N4.- 
A compound produced by the action of formalde- 
hyd on ammonia. The drug has other trade 
names-cystogen, aminoform, formin, uritone. 
Urotropin increases the excretion of the urine and 
of uric acid, the solution of the urates beginning 
within 24 hours. Urotropin is decomposed in the 
organism, formaldehyd being set free and being 
eliminated in the urine. Ordinary medicinal 
doses cause no general effects as a rule, but in 
susceptible persons it may cause gastric and renal 
irritation, with hematuria, hemoglobinuria, and 
albuminuria, also diarrhea, abdominal pain, a 
measley rash, headache, tinnitus aurium, and 
strangury. It is an excellent urinary and intesti- 
nal antiseptic, and possesses considerable power 
as a solvent of uric acid, the excretion of which it 
promotes. It is particularly efficient as an altera- 
tive and diuretic in the treatment of cystitis, 
pyelitis, and phosphaturia. It is advocated as a 
prophylactic against scarlatinal nephritis and 
threatened meningitis. The dose for adults is 
7 1/2 grains, 2 or 3 times daily, best administered 
in 1/2 pint of plain or carbonated water. No 
more than 30 grains should be given in a day. 
URTICARIA (Hives; Nettle-rash).-An inflam- 
matory affection of the skin, characterized by the 
formation of evanescent whitish and pinkish ele- 
vations, attended by intense itching. 
Symptoms.-The eruption appears suddenly, 
manifesting itself as firm, circumscribed, whitish 
or pinkish elevations (wheals, pomphi) with a red- 
dish areola. The wheals last from a few minutes 
to several hours, disappear, and are succeeded by 
others. They are asymmetric, though usually 
bilateral, pea-sized or bean-sized, and irregular in 
shape, often, however, being linear. They may 
involve any portion of the cutaneous surface, or 
even the mucous membranes. When the pharynx 
or larynx is involved, alarming suffocative attacks 
may occur. 
The itching in urticaria is intense, the relief 
produced by scratching being purchased at the 
cost of the excitation of new lesions. The skin is 
markedly sensitive to all sorts of irritation, and 
responds by the production of wheals. The 
artificial production of wheals gives rise to the 
form termed urticaria factitia. In some urticarial 
subjects a word may be inscribed upon the skin 
with a pointed instrument, and in a few minutes 
the letters will stand out in wheals as if embossed. 
In children urticaria is apt to take the papular 
form-urticaria papulosa (lichen urticatus). In 
such cases there are actual inflammatory papules 
present, with or without the presence of wheals. 
The summits of the papules are apt to be excoriated 
on account of the scratching prompted by the intol- 
erable itching. In some individuals wheals attain 
the size of an egg or even larger. This form is 
called urticaria tuberosa or urticaria gigans (giant 
urticaria). Hemorrhage into the wheal occurs 
occasionally, giving rise to the form known as 
urticaria hoemorrhagica. At times the upper layers 
of the wheal are raised into a bleb by the subjacent 
serum; this type is designated urticaria bullosa. 
Urticaria, as a rule, runs an acute course, sub- 
siding in a few days. In exceptional instances, 
however, it may become chronic, wheals appear- 
ing, disappearing, and reappearing, the process 
extending over a period of months or even years. 
Etiology.-The great majority of cases of acute 
urticaria are produced through the alimentary 
tract. Substances taken into the stomach may 
cause urticaria, either by a mechanic irritation of 
the stomach or bowel or by producing a toxemia. 
Intestinal parasites and undigested aliment act by 
mechanic irritation. The substances capable of 
producing toxemia are almost numberless. They 
may be primarily toxic, or may only develop their 
toxicity through putrefactive changes while in 
the bowel. Again, a large number of substances, 
both foods and drugs, perfectly innocuous to the 
ordinary individual, act, on account of idiosyn- 
crasy, as poisons to others. The following articles 
of food are particularly apt to produce hives: 
lobsters, crabs, mussels, cheese, sausage, pork, 
nuts, strawberries, etc. 
The following drugs are prone to produce urti- 
carial eruptions: quinin, copaiba, cubebs, salicylic 
acid, morphin, turpentine, chloral, etc. Urticaria 
may be produced reflexly also by irritation of 
viscera other than the alimentary tract. It is 
sometimes associated with rheumatism and tonsil- 
litis. Thus, irritation of the uterus and adnexa 
may act as an etiologic factor. Rupture or 
puncture of hydatid cysts or puncture of pleural 
effusions may be followed by hives. Again, the 
disease may be produced by direct local irrita- 
tion, such as the sting of the nettle, the bite 
of jelly-fish, mosquito, wasp, etc. 
Pathology.-The wheal is produced as a result 
of direct reflex disturbance of the vasomotor 
apparatus. The lesion consists of a circumscribed 
edema of the cutis. A momentary spasm of the 
cutaneous vessels is followed by a dilatation, with 
exudation of serum and some leukocytes. At the 
summit of the lesion the effusion is so great as to 
produce a pressure anemia, hence the whitish 
coloration. The peripheral vessels are engorged, 
which gives rise to the reddish areola. 
Diagnosis.-The characteristic features of urti- 
caria are the presence of wheals, their rapid evolu- 
tion and great evanescence, and the intense 
itching. URTICARIA PIGMENTOSA 
UTERUS, CARCINOMA 
Prognosis.-Acute cases recover in a few days. 
Chronic cases may persist for a long time, and may 
exhaust the entire therapeutic armamentarium 
of the physician. 
Treatment.-In severe acute cases seen early an 
emetic should be administered to get rid of the 
offending substance. Later, magnesium sulphate 
is to be employed until free catharsis is produced. 
In subacute cases salol or phenacetin, in 5- to 10- 
grain doses after meals, may be used with good 
results. In chronic cases most earnest efforts 
should be directed toward the discovery of the 
cause. The patient's dietary must be the subject 
of the most careful study. Every detail of occu- 
pation, of mode of living, and of habits must be 
scrutinized. The most careful examination, how- 
ever, will sometimes fail to disclose any discover- 
able cause. Most cases will be found to be due to 
gastrointestinal disturbances. In such the most 
simple diet should be prescribed. In obstinate 
cases one will do well to restrict the patient for a 
few weeks to a milk diet. 
In obscure cases some of the following remedies 
may be tried: atropin by mouth or hypodermically, 
antipyrin or phenacetin, quinin in full doses, sul- 
phurous acid in dram doses, long-continued course 
of arsenic in small doses, bromid of potassium, 
pilocarpin, etc. 
Local treatment is necessary to give relief from 
the harassing itching. The best antipruritic 
lotions are: Phenol, 1 to 3 drams to the pint; 
menthol, 5 to 15 grains to the ounce; liquor 
carbonis detergens, 2 to 3 drams to 8 ounces of 
water; saturated solution of benzoic acid; alkaline 
baths (1/4 of a pound of washing soda to 20 
gallons of water), etc. 
URTICARIA PIGMENTOSA.-An inflammatory 
affection of the skin, beginning in the first 6 months 
of infancy, and characterized by buff-colored, 
wheal-like nodules, with or without itching. 
Symptoms.-The eruption is most abundant 
upon the neck and trunk. It consists of yellowish- 
red, split-pea-sized nodules or wheals with pinkish 
areolas. The nodules later become yellow, and 
may remain stationary for months. Some under- 
go involution, leaving brownish stains. Itching is 
often severe, but may be moderate or entirely 
absent. The disease is very rare. 
Prognosis.-The affection usually disappears at 
or before puberty. 
Treatment.-Locally, antipruritic applications. 
Internal treatment is to be based upon general 
indications. 
UTERUS, ANTEFLEXION.-A bending forward 
of the fundus of the uterus upon the cervix. This is 
the normal position of the uterus, but it may be 
exaggerated sufficiently to cause obstruction of the 
cervical canal-producing dysmenorrhea and steril- 
ity-when it is regarded as pathologic. The point 
of flexion is usually at the site of the internal os. 
Causes.-It is usually congenital in origin, and 
is due to imperfect development of the body of the 
uterus; It is frequently associated with imperfect 
development of the rest of the genital organs- 
tubes, ovaries, and vagina. It is possible that it 
may be caused by improper hygienic conditions 
about the age of puberty, such as improper cloth- 
ing, insufficient exercise, etc. It is extremely rare 
to find pathologic anteflexion in a woman who has 
borne children. 
Symptoms.-The most important symptom is 
dysmenorrhea. The pain is quite characteristic. 
It is expulsive in character, and is situated in the 
center of the hypogastric region. It begins several 
hours before the appearance of the menstrual dis- 
charge, and is gradually relieved as the bleeding 
becomes free. The blood is usually dark colored 
and clotted. Sterility is commonly present in 
anteflexion of the uterus, since the obstruction in 
the cervical canal prevents the entrance of sper- 
matozoa. The imperfect development of the 
genital organs is a further cause of sterility. The 
interference with the menstrual flow will finally 
cause endometritis, which, in its turn, may cause 
inflammation of the tubes and ovaries. 
Diagnosis.-Bimanual examination will reveal 
the anterior position of the fundus, with the sharp 
angle of flexion between it and the cervix. These 
physical signs and the symptoms just described 
will make an absolute diagnosis of pathologic 
anteflexion. 
Treatment.-Pathologic anteflexion of the uterus 
should be treated by rapid and forcible dilatation 
of the cervix. This is performed in the following 
manner: The patient is etherized and placed in the 
lithotomy position; the vulva, vagina, hands, and 
instruments are thoroughly sterilized. The ante- 
rior lip of the cervix is seized with a double tenacu- 
lum and drawn well down toward the vulva. The 
small uterine dilator (Wathen's) is introduced, and 
the cervix is gently dilated 1/2 of an inch or more. 
This is followed by the introduction of the larger 
dilator. With this instrument the cervix is 
gradually dilated up to 1 inch or 1 1/4 inches. To 
secure a more permanent result, the instrument 
should be allowed to remain in place 10 or 15 
minutes after full dilatation has been accomplished. 
The instrument is withdrawn and the cervical 
canal and the vagina are douched with sterile 
water. A tampon of iodoform gauze is inserted 
into the vagina; this is removed at the end of 24 
hours, and a douche of sterile water is given. The 
patient should remain in bed a week or 10 days 
after the operation. The first menstrual period 
following the operation may be attended by some 
pain, but usually the subsequent periods are pain- 
less. In exceptional cases it may be necessary 
to repeat the operation. 
UTERUS, CARCINOMA.-For description of 
carcinoma of the cervix see Cervix Uteri. 
Cancer of the body of the uterus is a somewhat 
rare condition when compared to cancer of the 
cervix. It occurs in only about 2 percent of all 
cases of cancer of the uterus. It originates in the 
epithelium of the endometrium. 
The causes of cancer of the body of the uterus 
are not known. Chronic inflammation of the 
mucous membrane may be a predisposing cause. 
It occurs later in life than cancer of the cervix- 
usually between the fiftieth and sixtieth years- 
and it may attack the nulliparous as well as the 
parous woman. UTERUS, CERVIX 
UTERUS, FIBROID TUMORS 
The symptoms of cancer of the body of the uterus 
are about the same as those of cancer of the cervix. 
There are pain, hemorrhage, and leukorrheal dis- 
charge. Vaginal examination shows an enlarged 
uterus and a patulous cervical canal. When any 
doubt exists as to the nature of the condition, the 
uterus should be curetted and the scrapings 
examined under the microscope. 
The treatment should be complete Hysterec- 
tomy (q. v.). Either the vaginal or the abdominal 
route may be selected for this operation. Early 
hysterectomy in these cases offers a very favorable 
prognosis. 
In inoperable cases recently acetone applica- 
tions or douches have been advocated to stop the 
bleeding and discharge and improve the general 
condition. The chief palliative measure is curet- 
tage followed by the use of Paquelin's thermo- 
cautery. Hemorrhage may be controlled by 
injections of adrenalin chlorid. It is advisable 
after the cauterization to apply for a few minutes 
a tampon soaked with formalin. After the curet- 
tage some advocate the application of zinc chlorid 
or iodized phenol. Permanganate of potassium 
solution is an excellent disinfectant. 
When the area of disease is very extensive 
tamponades wet or dry may be used to control 
the hemorrhage and irrigation with potassium 
permanganate solution should be employed for the 
copious offensive discharge. 
Sarcoma of the uterus is rare. Two varieties 
have been described: diffuse sarcoma of the mucous 
membrane and sarcoma of the uterine parenchyma. 
The symptoms of the former closely resemble those 
of cancer of the body of the uterus; of the latter, 
those of fibroid tumor of the uterus. The treat- 
ment is complete hysterectomy. 
UTERUS, CERVIX.-See Cervix Uteri. 
UTERUS, FIBROID TUMORS.-Fibroid tumors 
of the uterus are benign but not harmless. They 
undermine the health and shorten life by hemor- 
rhage, interfere mechanically with the functions 
of vital organs, become septic, and undergo trans- 
formation into sarcoma. 
Structure.-Uterine fibroid tumors consist of ele- 
ments similar to those composing the normal struc- 
ture of the uterine walls, in which they originate. 
Connective tissue and muscular fibers are found in 
varying proportions. The terms used to designate 
these growths are fibroma, myoma, fibromyoma, 
and myofibroma; the two latter indicate the vary- 
ing preponderance of fibroid or muscular tissues. 
While of mixed character histologically, the natu- 
ral history of the several varieties is practically the 
same; hence the common term of fibroid tumors 
will serve to designate the neoplasms under con- 
sideration. These growths vary in size from a 
small nodule the size of a pea to an immense mass 
weighing more than 100 pounds. They are seldom 
single, though one or more may outgrow all others 
and present the appearance of a single rounded or 
nodular tumor. They originate in the body of the 
uterus, most frequently from the posterior wall. 
Classification.-It is customary to classify them 
in accordance with their relation to the normal 
uterine structures. When situated in the uterine 
wall, they are termed interstitial; when projecting 
outward beneath the peritoneum, they are called 
subserous; and when protruding into the cavity 
of the uterus, they are known as submucous. 
When starting from the supravaginal cervix and 
growing outward between the folds of the broad 
ligaments, they are termed intraligamentous. 
The tumors grow in the direction of least resistance 
and the proximity of the point of origin to the 
peritoneum or uterine cavity will determine 
whether a given fibroid tumor will be subserous, 
submucous, or interstitial. The tumor may be 
so connected with the uterine wall as to become 
pedunculated. As a result of traction, pressure, 
or atrophy the pedicle may become twisted, pro- 
ducing gangrene. When the tumor originates near 
the uterine mucosa and grows beneath that 
membrane, it may become extruded into the uter- 
ine cavity, forming a pedunculated tumor. This 
is known as a fibroid polypus. Such a tumor will 
gradually adapt itself to the form of the uterine 
cavity. Its presence excites uterine contraction, 
and after a time it will be forced through the 
cervix into the vagina. The vascular supply is 
lessened by this process, and sloughing is very 
common. The fibroid polypus is more frequently 
single than any other variety of fibroid tumor 
of the uterus. 
Progress.-Uterine fibroid tumors vary in con- 
sistence from the soft, edematous myofibroma 
to the hard nodules almost wholly composed of 
fibroid tissue. As a rule, they are of slow growth; 
in exceptional instances they increase with the 
rapidity which characterizes ovarian tumors. 
They frequently cease to grow after the meno- 
pause, while in exceptional instances they take 
on increased activity after that change. In some 
cases the tumor reaches a certain growth and re- 
mains inactive, while in other instances it steadily 
increases until it occupies the entire abdominal 
cavity and causes serious symptoms by pressure. 
During menstruation and pregnancy tumors in- 
crease in size. After parturition marked diminu- 
tion in size takes place, so that a tumor that was 
conspicuous becomes almost imperceptible. 
Sequels.-The tumors under consideration are 
subject to several forms of degeneration. Edema 
of these growths is quite common. The entire 
structure of the tumor becomes infiltrated with a 
serous fluid. This condition is closely allied to 
cystic degeneration, in which the constituent 
elements of the tumor are displaced by serous 
fluid. Cystic cavities may occur as the result of 
several degenerative changes, the growth being 
then known as a fibrocystic tumor. Inflammation 
may be present in fibroid tumors, often resulting 
from instrumentation and other agencies. Sup- 
puration may take place. Fibroid tumors of the 
uterus are prone to sarcomatous degeneration. 
Some pathologists maintain that uterine sar- 
coma invariably begins in degeneration of a fibroid 
tumor. Clinical observation has so far confirmed 
this view that fibroid tumors are generally regarded 
as predisposing to sarcoma. Carcinoma is fre- 
quently associated -with fibroid tumors; but since 
carcinoma most frequently occurs in the cervix, UTERUS, FIBROID TUMORS 
UTERUS, FIBROID TUMORS 
and fibroids in the body of the uterus, it cannot be 
claimed that fibroids are disposed to undergo 
carcinomatous changes. 
Age, Race, etc.-Uterine fibroid tumors are 
common in both the white and black races, but 
more frequent in the latter. They are found in 
both nulliparous and multiparous women; indeed, 
these tumors are among the most common of all the 
diseases peculiar to women. Unmarried women 
and married women who have never conceived are 
especially prone to this disease; from which it is 
apparent that the arrest of menstruation by 
pregnancy and lactation, and the retrograde 
changes accompanying involution, are means of 
protection against the development of these neo- 
plasms. 
Symptoms.-Hemorrhage is the most conspic- 
uous symptom of fibroid tumors of the uterus. 
While this symptom is observed in the majority 
of cases, it is not invariably present. Large in- 
terstitial and subserous tumors may exist without 
hemorrhage. Small subserous tumors may present 
no symptoms. Hemorrhage may occur as a profuse 
and prolonged menstrual period (menorrhagia), 
or as a continuous uterine hemorrhage (metror- 
rhagia). Hemorrhage may be so profuse as to 
exhaust the patient, or it may be only sufficient 
to produce a moderate degree of anemia. In cases 
of submucous tumors (fibroid polypi) the hemor- 
rhage may be so severe as to exsanguinate the 
patient. The increased area and diseased condi- 
tion of the endometrium account for the hemor- 
rhage. The site, more than the size of the growth, 
determines the severity of the hemorrhage. 
Pain is a comnion accompaniment of these 
tumors. It is the result of various causes, and 
hence varies in character. The pain of pressure 
corresponds more to the location than to the size 
of the growth. When the tumor springs from 
the lower uterine segment and fills the pelvic 
excavation, the pressure upon bladder, bowel, and 
nerve-trunks will give rise to more severe pain 
than w'hen the tumor rises free above the pelvic 
brim. Pressure upon the bladder, producing vesi- 
cal irritation, and pressure upon the bowel, induc- 
ing constipation and hemorrhoids, are common. 
Endometritis, salpingitis, and peritonitis are fre- 
quent complications, and cause constant and severe 
pain. The expulsion of submucous fibroid tumors 
from the uterus is accompanied by the pain of uter- 
ine contraction. The bladder and urethra may be 
so distorted by the growth of a fibroid tumor that 
the urine is voided with much pain and difficulty. 
The diagnosis is made by observing the symp- 
toms just described, together with careful physical 
examination. The presence of a tumor, its 
irregular outline and solid structure, together 
with its immediate attachment to the uterus, can 
be determined by bimanual examination. If the 
tumor is large, its firm consistency and nodular 
character can be detected by palpation through 
the abdominal parietes. Interstitial fibroid tumors 
producing symmetric hypertrophy of the uterus 
are liable to be mistaken for pregnancy. This 
is especially marked in the soft and edematous 
tumors. While generally the diagnosis between 
uterine fibroma and, pregnancy is not difficult, yet 
one condition has been mistaken for the other, 
and the error was not discovered until the abdo- 
men was opened. The coexistence of fibroid 
tumors and pregnancy is not very infrequent, and 
this fact should be borne in mind. 
The differential diagnosis between ovarian 
cystoma and the soft, edematous variety of 
uterine fibroid tumors is often most difficult, and 
to distinguish between a fibrocystic tumor and an 
ovarian cystoma is also at times exceedingly 
difficult. Fluctuation exists with all of these 
alike, and the differential diagnosis can only be 
made by determining the relation of the growth 
to the uterus, as indicated by direct mobility 
of the cervix when the tumor is manipulated 
through the abdominal parietes. An error in 
diagnosis here is fortunately not of serious conse- 
quence, since the treatment of all tumors of such 
magnitude consists in removal by abdominal 
section. 
Fibroid tumors springing from the lower seg- 
ment of the uterus, with adhesions, may readily 
be mistaken for intrapelvic inflammatory exudate 
associated with pyosalpinx and ovarian abscess. 
The reverse of this is also true. 
In the diagnosis of submucous fibroids direct 
exploration of the interior of the uterus with the 
finger will usually suffice to disclose the character 
of the growth. 
Treatment.-The tendency of submucous fibroid 
tumors of the uterus is to spontaneous cure by 
becoming polypoid in character, to be afterward 
extruded from the uterine cavity by persistent 
uterine contraction. In a majority of cases pre- 
senting this form of fibroid growths the tumors 
will be found projecting from the external os. 
They vary in size from that of a walnut to large 
rounded tumors as large as the fetal head at term. 
If the tumor has been extruded from the uterine 
cavity through the cervical canal, its removal may 
be readily and safely accomplished. The danger 
of hemorrhage after excision in such cases is not 
serious. Indeed, the blood supply in such growths 
has been so reduced by the process of peduncula- 
tion and protrusion by uterine contraction that the 
tumor very frequently sloughs from obstructed 
circulation. It is, however, safer to constrict the 
pedicle with a wire snare or ^craseur, thus slowly 
crushing the pedicle containing the vascular sup- 
ply, than to divide it with knife or scissors. In 
cases of large fibroid polypi that fill the vagina 
completely it will often be necessary to remove 
the greater part of the tumor by morcellation 
before the surgeon can gain access to the pedicle. 
If the pedicle persists in bleeding after excision of 
the tumor, the vessels may be caught in a clamp 
forceps, and left thus secured for 24 hours. Usu- 
ally, firm packing with gauze will suffice to control 
the bleeding. This, of course, should only be done 
after thorough scrubbing of the external genitals 
with hot water, soap, and brush, the application of 
an antiseptic douche, and all other aseptic pre- 
cautions. For the operation, the patient should 
be placed on a table in the lithotomy position, the 
perineum should be retracted with Sims' speculum, UTERUS, FIBROID TUMORS 
UTERUS, FIBROID TUMORS 
and the uterus should be brought down and 
steadied by means of strong tenaculum forceps. 
If a submucous fibroid tumor is within the 
uterine cavity, it will be necessary to dilate the 
cervix in order to reach the growth and remove it. 
If the tumor is sessile and low down, and if it can 
be drawn down near the internal os, the capsule 
will have to be opened at the most dependent point 
and stripped away, when the tumor can be seized 
with the volsellum upon its uncovered surface and 
enucleated by the finger of the surgeon. Care 
must be observed, if instruments are used in 
enucleating, not to penetrate the wall of the uterus. 
If the capsule is not injured in this procedure, the 
hemorrhage will be slight, and gauze packing will 
readily control it. After completing the operation 
the vagina should be lightly packed with gauze, a 
pad applied to the vulva, and the patient kept 
quiet in bed for a week. After from 24 to 48 hours 
the gauze should be removed and the vagina 
douched with pure hot water. 
The treatment of subserous and interstitial fibroid 
tumors of the uterus requires the exercise of sound 
judgment, based on the requirements of individual 
cases. When the tumor is of small size, unac- 
companied by pain, hemorrhage, or other serious 
symptoms, operation should not be advised, and 
no special treatment will be required. Under these 
conditions the patient should be kept under 
occasional observation and no treatment need be 
instituted so long as the growth does not markedly 
increase and while health and comfort are main- 
tained. This course is especially applicable to 
women with tumors of considerable size who are 
near the menopause. The mere presence of a 
small subserous or interstitial fibroid does not 
indicate any form of treatment and does not forbid 
activity and exercise on the part of the patient. 
It is only when such symptoms as hemorrhage 
with anemia, pressure, and pain are present that 
symptomatic and palliative treatment is indicated. 
For all these symptoms rest is most important. 
Especially should rest be observed during the 
menstrual periods. Mild purgation with salines 
relieves congestion by depleting the pelvic circula- 
tion, and should be conjoined with rest during the 
periods. For excessive hemorrhage various drugs 
-such as ergot, gallic acid, hydrastis, and some 
preparations of iron-are in popular favor for 
controlling the bleeding of uterine fibroids, but 
usually have proved wholly inefficient; and their 
use begets constipation and congestion, impairs 
the appetite and digestion, and interferes with the 
eliminative functions generally. Hemorrhage will 
be more restrained by rest, saline purgatives, un- 
stimulating diet, and the moderate use of the hot 
vaginal douche than by the remedies mentioned. 
Recently, thyroid extract, internally administered, 
has been highly recommended to control the hem- 
orrhage and to arrest the growth of uterine fibroids, 
but experience with its use, though limited to a 
comparatively few cases, has failed to justify the 
claims made for this remedy. For excessive 
hemorrhage the most efficient treatment is to curette 
the uterine mucosa and to pack the cavity with 
sterilized gauze. This operation, of course, should 
be done with careful observance of all antiseptic 
precautions and in a thorough and surgical way. 
Electricity does not arrest the growth of the 
tumor, and the results claimed for it as a hemo- 
static have not been verified by general experience. 
Electropuncture has proved harmful instead of 
efficacious, on account of the traumatic peritonitis 
following this procedure. 
With the improved technic of modern pelvic 
surgery the operation for removal of uterine fibroid 
tumors has become so perfected that palliative and 
expectant methods of treatment have given way 
to surgical intervention. In skilled hands, and 
especially with the facilities of modern hospital 
requirements, the mortality of operations for 
removal of these growths has been reduced quite 
as low as that following operations for the removal 
of ovarian tumors. 
While the methods of treatment outlined may 
alleviate symptoms and prolong life, and while 
such treatment is eminently appropriate in cases 
of small tumors without active hemorrhage or 
severe pain, surgical measures alone can afford the 
patient permanent relief and cure. Hence, in the 
majority of cases resort to operative intervention 
is indicated. The adaptation of the operative 
procedure to individual cases requires the highest 
surgical skill and experienced judgment. 
Formerly, when the results of operation were 
marked by severe mortality, women suffering 
from these tumors were consigned to invalidism, 
with much suffering, through the active period of 
life, looking to the menopause for relief. Many 
died from the pressure effects and hemorrhage of 
large tumors; others succumbed to the accidents, 
complications, and degenerations to which these 
growths are prone; while still others found the 
menopause deferred or the tumor growing actively 
after that period. With the perfected methods of 
modern surgery the dangers of operation have been 
reduced until they are less than the dangers in- 
separably connected with the natural progress of 
these tumors. Operative treatment is now so safe 
that it is not to be restricted to large tumors, or to 
smaller growths complicated in various ways by 
which life is directly threatened; but in cases of 
fibroid tumors in which the health is impaired by 
hemorrhage and pressure of less urgency, but 
sufficient to beget invalidism,. permanent relief 
should be sought through operative intervention. 
When the tumor is growing actively, and the 
patient is suffering from pressure and is weakened 
by hemorrhage, protracted delay to await the 
increase of symptoms is inadmissible. 
The operations which have been devised for the 
cure of uterine fibroids are: (1) Removal of the 
uterine appendages; (2) ligation of the uterine 
arteries through the vagina; (3) myomectomy; 
and (4) hysteromyomectomy. The first two pro- 
cedures are practically abandoned. The operation 
of myomectomy (removal of the tumor and preser- 
vation of the uterus) is practised whenever 
practicable. In most cases of multiple fibroids, 
and in cases in which the uterus is distorted and 
enveloped by the growth, hysteromyomectomy is 
indicated. See Hysterectomy. UTERUS, INFLAMMATION OF THE MUCOUS MEMBRANE 
UTERUS, INFLAMMATION OF THE MUCOUS 
MEMBRANE (Endometritis).-Inflammation of the 
mucous membrane of the body of the uterus, or 
corporeal endometritis, may be acute or chronic. 
Acute corporeal endometritis is the result of the 
introduction into the uterus of septic microorgan- 
isms. This usually occurs during labor or miscar- 
riage, or it may result from operations, such as 
dilatation, or from the introduction of an unclean 
sound. It sometimes occurs as a complication of 
the exanthems. If the process is severe enough, 
it may involve the muscular tissue underneath the 
mucous membrane, when it is called metritis; or 
the peritoneal covering of the uterus may be 
invaded, when it is called perimetritis. See 
Colon Bacillus Infection. 
Symptoms.-Acute corporeal endometritis is 
usually attended by considerable pain, of a dull, 
aching character. There are constipation and 
vesical irritability. The pulse is rapid and tem- 
perature in some cases is very high-from 104° to 
106° F. Vaginal examination reveals a patulous 
cervical canal with a profuse purulent discharge 
escaping from it. The uterus is enlarged, boggy, 
and tender. 
Treatment.-Acute corporeal endometritis fol- 
lowing miscarriage or labor should be treated ac- 
tively. The uterus should be thoroughly curetted, 
in order to remove any portions of decidua or mem- 
branes remaining after parturition. If the symp- 
toms do not subside in the course of 24 hours, 
intrauterine douches of sterile water may be given 
2 or 3 times daily. Free purgation, hot stupes to 
the lower abdomen, a generous diet of milk and 
broths, and an abundance of stimulation will be 
required. In the gravest cases hysterectomy will 
have to be performed. In less severe cases of 
acute endometritis rest in bed, vaginal douches of 
hot, sterile water, and purgation will be sufficient. 
Chronic corporeal endometritis may result from 
an acute attack or it may be chronic from the 
beginning. One of the most frequent causes of 
this condition is gonorrheal infection. Chronic 
endometritis accompanies a variety of pathologic 
conditions of the uterus, such as displacements, 
subinvolution, laceration of the cervix, and fibroid 
tumors. 
Two varieties of chronic endometritis have been 
described-glandular and interstitial. 
The symptoms of chronic endometritis are usu- 
ally well marked. There is pain, of a dull, aching 
character, most evident in the back and extending 
down the thighs. Leukorrhea is constant, and is 
quite characteristic. The discharge is thin, puru- 
lent, and blood-streaked. Menstruation is profuse, 
and lasts usually from 5 to 7 days. The patient's 
general health suffers; she loses weight and becomes 
anemic; there is a sense of great reduction in phys- 
ical strength. Headache is a very common symp- 
tom. Nervous, digestive, and circulatory dis- 
turbances appear sooner or later. Physical exam- 
ination reveals an enlarged, tender uterus. The 
cervical canal is patulous; the external os is eroded. 
The characteristic discharge can be seen escaping 
from the cervix. 
The treatment of chronic corporeal endometritis 
will depend upon its cause. It may be necessary 
to replace a displaced uterus, to remove a fibroid 
polypus, or to repair a lacerated cervix or perineum. 
If the condition is due to gonorrheal or septic 
infection, or if the foregoing measures fail, curet- 
tage should be performed. 
The steps of the operation are as follows: The 
patient is prepared for the operation, anesthetized, 
and placed upon the table in the dorsal position. 
The anterior lip of the cervix is seized with a tenac- 
ulum and is drawn well down toward the vulva. 
The cervical canal is dilated about 1 inch. A Sims 
sharp curette is introduced, and the anterior, lat- 
eral, and posterior surfaces of the uterus are care- 
fully and thoroughly scraped. This is followed by 
careful scraping of the fundus and of the region 
around the uterine opening of the Fallopian tube 
with a Martin curette. The uterus is now irrigated 
with sterile water, and the vagina is packed lightly 
with iodoform gauze. The gauze is removed at the 
end of 24 hours, the bowels are evacuated at the 
end of the second day, and the patient is allowed 
to get out of bed at the end of 10 days or 2 weeks. 
If the disease is gonorrheal in origin, the uterine 
cavity, after curettage and irrigation, should be 
wiped out with pure carbolic acid. The excess 
of carbolic acid may be removed by another douche. 
After curettage the first and sometimes the sec- 
ond and third menstrual periods are missed. 
Attention to the general health, diet, exercise, and 
condition of the bowels, and the administration of 
tonics will be required before complete cure is 
accomplished. 
Tuberculous endometritis is rare and is generally 
secondary to tuberculosis of the tubes or cervix. 
Diagnosis may be made by the removal of caseous 
material by means of the curette, or by the 
tuberculin test. See Endocervicitis under Cer- 
vix Uteri. 
UTERUS, PROLAPSE.-A sinking of the uterus 
below its normal level. There are a great many 
degrees of prolapse of the uterus. It may vary 
from a slight sinking of the organ to complete 
extrusion from the vulvar orifice. 
Causes.-The most frequent cause of prolapse 
of the uterus is injury at childbirth-laceration of 
the perineum. Other causes are: relaxation and 
elongation of the uterine ligaments; loss of rigidity 
of the abdominal walls; diminution of the cellular 
tissue and fat of the pelvis; increase in the weight 
of the uterus from subinvolution or congestion; 
and, finally, anything that may cause an increase 
in intraabdominal pressure, as constant coughing, 
violent straining, or heavy lifting. 
Symptoms.-The symptoms of prolapse of the 
uterus are not characteristic; neither do they cor- 
respond in severity to the degree of prolapse. 
Slight descent of the organ may cause more disturb- 
ance than complete prolapse. The patient usu- 
ally complains of pain in the back, head, and thighs. 
The pain in the back is dull and aching in charac- 
ter, and is usually felt most severely over the 
sacrum. Added to this there is a dragging and 
feeling of loss of support in the pelvis. Constipa- 
tion and irritability of the bladder are usually 
present. 
UTERUS, PROLAPSE UTERUS, REMOVAL 
UTERUS, RETRODISPLACEMENTS 
Diagnosis.-Physical examination will readily 
reveal the condition. The cervix or body of the 
uterus may project from the vulva. In less 
severe cases the cervix may be found resting on 
the pelvic floor. Slight cases of prolapse are the 
most difficult to diagnose. It will be found, how- 
ever, that the cervix is lower than normal, and 
that the uterus can be pushed further upward than 
usual. It should be remembered that when the 
patient lies on her back, the prolapse is less marked 
than when she is erect. Complete prolapse of the 
uterus should never be mistaken for inversion of 
the uterus or for a uterine polypus, since their 
only point of resemblance is in shape. 
Treatment.-The treatment of prolapse of the 
uterus is operative, unless some contraindication 
to operation exists. In such a case some mechanic 
device should be tried for the support of the uterus. 
Pessaries are not to be recommended, as their 
constant use leads to irritation and excoriation of 
the vaginal walls. Probably the best means for 
supporting the uterus is by an instrument called 
Braun's colpeurynter. This instrument is worn 
only during the day, and can be introduced by the 
patient herself every morning. The uterus is 
replaced and the colpeurynter, well anointed with 
carbolized vaselin and containing about an ounce 
of water, is introduced into the vagina. It is then 
distended with air, thus making an even pressure 
on the vaginal walls and not causing ulcerations. 
Operative treatment gives the most satisfactory 
results in prolapse. In slight cases of prolapse 
repair of the Perineum (q. v.) will effect a cure. 
The severer grades will require, in addition, some 
operation on the anterior vagina-anterior col- 
porrhaphy. The best of these is Martin's opera- 
tion for cystpcele. Dudley advocates an ellip- 
tical bilateral denudation of the vaginal walls. 
See Cystocele. 
If the cervix is hypertrophied it should be 
amputated. See Cervix Uteri. 
These three operations-Emmet's operation 
on the perineum, Martin's operation for cystocele, 
and amputation of the cervix-are required in the 
usual case of prolapse. In addition, hysteror- 
rhaphy may be advisable, since there can be no 
prolapse so long as the uterus maintains its normal 
position of anteflexion. These operations failing, 
Hysterectomy (q. v.) may be performed. 
UTERUS, REMOVAL.-See Hysterectomy. 
UTERUS, RETRODISPLACEMENTS.-R e t r o - 
displacements of the uterus comprise retrolocation, 
retroversion and retroflexion. In retrolocation 
the organ may retain its normal relation to the 
pelvic axis, but the entire organ is displaced back- 
ward. This displacement is the result of some 
inflammatory process in the pelvic peritoneum 
by which the uterus has been fixed, most frequently 
by a collection in the retrouterine pouch which 
has been absorbed. 
Retroversion is a rotation of the uterus on its 
transverse axis by which the fundus of the organ is 
carried backward and the cervix looks forward. 
Retroflexion is a change in the vertical axis 
of the uterus in which there is a more or less acute 
angle on its posterior surface between the fundus 
and cervix. It is usually associated with retro- 
version, indeed, may be regarded as a later stage 
of that displacement. Both retroversion and 
retroflexion may vary from a slight backward 
displacement, to one of extreme degree, where 
the fundus in the former, is situated in the pouch 
between the rectum and the vagina, while the cer- 
vix looks directly forward or forward and upward. 
In the latter, the cervix may occupy the axis of 
the vagina, while the fundus is below its level. 
Retroversion is the first stage of prolapse, con- 
sequently it is very frequently associated with 
the latter condition. Not infrequently an ante- 
flexed uterus will also be found retroverted. 
Diagram of the Degrees of Retroversion of the 
Ute rus .-{Penrose.) 
Etiology.-Backward displacements of the uterus 
are most frequently sequels of parturition. With- 
out doubt, infection, to a more or less degree, is an 
essential factor. The uterus remains large and 
heavy, its ligaments, relaxed by the previous 
pregnancy, are kept in a continuous state of tension 
which prevents their involution, while the relaxed 
condition of the abdominal muscles from over- 
distention suspends the pow'er of aspiration. 
Improper hygiene in both the pregnant and non- 
pregnant is an important consideration. Habit- 
ual distention of rectum and bladder, and the 
straining of constipation result in loss of muscular 
power and increased uterine displacement. Main- 
tenance of the same waist measure, notwithstand- 
ing increase of size from pregnancy or additional 
adipose, necessarily causes greater intraabdom- 
inal pressure, and as the enlargement is unable to 
find accommodation elsewhere it is forced down- 
ward, not only adding to the displacement, but 
making it permanent. Flexions may be produced 
by irregular involution; thus an inflammation of 
the site of a placenta which had been implanted 
on the anterior uterine wall would result in more 
rapid involution of the posterior wall, causing it to 
become the string of the bow and draw the fundus UTERUS, RETRODISPLACEMENTS 
UTERUS, RETRODISPLACEMENTS 
backward. Displacements are produced by growths 
as fibroids, in the uterus or, from the pressure of 
external tumors, as ovarian cysts, tubal enlarge- 
ments and pelvic exudates. These displacements 
may occur in either the single or the married, the 
nulliparous or parous woman, though more 
frequent in the latter. 
Symptoms are not characteristic. Patients 
complain of headache, backache, a sensation of 
weight and dragging in the pelvis, pain and points 
of anesthesia down the thighs, menorrhagia and 
leukorrhea, dysmenorrhea, vesical irritability, 
obstinate constipation, hemorrhoids and anal fis- 
sures increasing discomfort in standing and walking, 
all of which may be aggravated just preceding 
menstruation, but, as is well-known, these symp- 
toms may be produced by other conditions. 
Their existence, however, should be sufficient 
cause for subjecting the patient to a careful 
pelvic examination. 
Diagnosis.-Retrodisplacements are readily de- 
termined by the bimanual examination. The 
cervix is situated near the vaginal outlet, in the 
axis of the vagina, looking forward or even up- 
ward. The fundus is absent from its normal 
situation behind the symphysis, lies posteriorly, 
and sometimes on the rectum. In retroflexion 
there is a distinct angle between the fundus and 
the cervix. Retrolocation is recognized by the 
organ being drawn upward and fixed near the 
sacrum. The only condition in which the diag- 
nosis is difficult is when the uterus is surrounded 
by a mass of exudate in which its relations are 
more or less lost, but here the inflammatory 
condition is the condition of greatest significance. 
Treatment.-Mechanical and surgical measures 
may be employed. The mechanical measures- 
pelvic massage, medicated tampons and pessaries 
-are applicable where the condition is recent. 
Where the uterus is still heavy from subinvolution 
following a recent pregnancy its elevation and 
maintenance in a proper position by a tampon or 
suitable pessary so improves the circulation as to 
rapidly restore it to its proper size, when its liga- 
ments will be sufficient to retain it. Tampons 
medicated by glycerin preparations have a hydra- 
gog effect on the uterus promoting its circulation 
and the more rapid absorption of the inflammatory 
or other products which caused the enlargement. 
They are especially beneficial as a supplementary 
treatment to pelvic massage in fixation of the 
uterus by inflammatory exudate. The necessity 
for operation in recent cases may frequently be 
avoided by the employment of this combined 
treatment The exudate is absorbed, the uterus 
freed, and the abnormal position corrected. 
This plan of treatment is futile in old inflammatory 
conditions, and positively dangerous in the pres- 
ence of suppuration. The maintenance of the 
uterus by the pessary in a corrected position is 
efficacious where the displacement and the condi- 
tion is uncomplicated. The uterus must be capa- 
ble of being placed in the correct position, and be 
so placed, before the pessary is inserted. The 
pessary does not correct the malposition, but main- 
tains the organ when replaced. 
Reposition and Insertion of the Pessary.-The 
uterus may be placed in its proper position in one 
of two ways. 1. With the patient in the dorsal 
position, the operator introduces, where possible, 
two fingers into the vagina with which the fundus 
is pushed up and the cervix backward; the other 
hand, on the abdomen, grasps the fundus and 
Thomas' Retroflexion Pessary. 
pulls it forward. The manipulation must be 
practised with the greatest gentleness and the 
continued cooperation of the patient be secured, 
otherwise but little can be accomplished. Occa- 
sionally, the prominence of the sacrum will be so 
marked that, by the methods just suggested, the 
fundus cannot be raised over it; in such circum- 
Smith-Hodge Pessary. 
stances, the cervix should be drawn upon with a 
tenaculum, or tenaculum forceps, and the fundus 
pushed forward with the finger in the vagina, 
after which the cervix can be carried backward 
with the forceps until the fundus is recognized by 
the external hand. 2. The patient should be 
placed in the genupectoral position and the vulva 
Mund^ Pessary. 
opened with a retractor, when the atmospheric 
pressure will carry the uterus upward, but not 
necessarily with the fundus forward. Should it 
still remain retroverted, the cervix can be 
grasped with the tenaculum forceps and drawn 
downward, and then carried backward, when it 
will be replaced unless there are firm adhesions 
fixing it. In this position the pessary can be UTERUS, RETRODISPLACEMENTS 
proper size of the pessary can be determined by 
measuring on the inserted fingers the length from 
the sacral promontory to the inner surface of the 
symphysis, and its width by the extent to which 
the fingers can be separated. An unduly large 
instrument will soon produce such ulceration and 
pain that it can not be worn and the cicatricial 
changes following its use will preclude the employ- 
ment of any other instrument. An instrument too 
small will be inefficient and necessarily prejudice 
the patient against further mechanical procedure. 
Pessaries of infinite variety have been devised. 
They are all, however, modifications of the original 
Hodge pessary. Instruments with a thick and 
wide posterior bar, are, generally the best, and of 
these the Mund^ and the Thomas are preferable. 
After the pessary has been inserted the patient 
should be directed to rise and sit down, if the 
presence of the instrument is unrecognized, she 
can be sent away with the assurance that it is 
unlikely to produce inconvenience. Should the 
instrument be partially protruded by straining at 
stool she should assume the genupectoral position 
before pushing it back. She should be instructed 
as to its removal and to permit the physician an 
opportunity within a week to see that it is causing 
no inconvenience. No pessary should be retained 
longer than two months without medical supervi- 
sion, and the vagina should be kept clean by douch- 
ing. Alkaline astringent douches should not be 
employed as they cause salts to be deposited on 
the pessary which roughen it and render its sub- 
sequent use a source of danger. When the 
pessary is continuously worn for a long period, it 
produces irritation and not unfrequently becomes 
more or less imbedded. In cases of chronic dis- 
placement, the pessary is objectionable as it is 
merely palliative and not curative. In retro- 
flexion, it is very unsatisfactory as the uterus is 
likely to fold over the pessary, and the same con- 
dition occurs when the organ has not been properly 
replaced before the introduction of the instrument. 
It will be appreciated that the uterus must be 
freely movable and capable of replacement to 
make the employment of a pessary practicable. 
The pessary is contraindicated in lacerations of 
the cervix, and will not be retained when there 
has been extensive laceration of the pelvic floor, 
or in great relaxation of the vagina. At best, the 
instrument is a crutch, requiring care that it does 
no injury, and should be regarded as only a 
temporary expedient. 
Surgical Measures.-The number of operative 
procedures devised for the correction of retrodis- 
placements is indicative that there exists no ideal 
procedure applicable to all cases, and that the 
operation must be adapted to the particular con- 
ditions present in the individual patient. Opera- 
tions have been adapted to the round ligaments 
at their exit from the inguinal canal and within 
the peritoneal cavity, to the uterosacral liga- 
ments, through the abdomen or the vagina, and 
various suspension or fixation operations through 
either vaginal or abdominal incision. 
The Alexander operation was the earliest sug- 
gested and performed for the radical restoration 
UTERUS, RETRODISPLACEMENTS 
introduced and carried under the uterus and its 
relation to the surrounding parts will be apparent 
to the eye of the physician. In the dorsal position 
the correction of the malposition is followed by the 
insertion of the pessary in the following manner: 
the left hand of the operator separates the labia 
Pessary in Faulty Position.-(Montgomery.) 
while the pessary, with its posterior bar held 
anteroposterior to the vulvar outlet, is made to 
impinge against the perineum and thus inserted 
until more than one-half the instrument is buried 
within the vagina, when it is rotated with the con- 
cavity of the greater curvature forward, and the 
[Pessary in Proper Position.-[Montgomery.) 
index finger of the right hand carries the posterior 
bar behind the cervix. The pessary should be 
sufficiently long to occupy the posterior vaginal 
fornix without undue pressure, and wide enough 
to fill the vagina and prevent displacement. The UTERUS, RETRODISPLACEMENTS 
UTERUS, RETRODISPLACEMENTS 
of the retrodisplaced uterus. (See Alexander's 
Operation). It is, however, applicable only to 
cases in which the uterus is freely movable, and 
consequently to those in which the operation is 
least demanded. It is a blind operation and not 
to be considered when the uterus is fixed by 
internal adhesions. 
Ventrosuspension or Ventrofixation devised by 
Olshausen and perfected by Kelly was for a time 
performed more frequently than any other opera- 
tion for retrodisplacements and afforded the ad- 
suture is not more than one-half an inch in width 
as the aim is to construct a ligament which will 
lengthen and not firmly fix the uterus against the 
abdominal wall. 
Vaginal Fixation.-Procedures aimed to main- 
tain the uterus forward through an incision of the 
anterior vaginal fornix have been devised. 
Duhrrsen secured the anterior wall of the uterus 
without opening the peritoneum, Mackenrodt 
opened the peritoneum and placed the suture 
higher on the fundus, Gottschalk and Vineberg 
secured a loop of the round ligament in the vaginal 
wound, Ries through the vaginal incision made a 
slit in the anterior wall of the uterus and secured a 
loop of each round ligament in it. Experience 
disclosed that fixation operations exercised a 
baneful influence in subsequent pregnancy, pro- 
ducing more or less discomfort during the gestation 
and became a cause of dystocia at its termination. 
In spite of careful precautions the operator would 
sometimes find that as a result of a slight infection 
or some other cause, an intended suspension had 
become a fixation. When most favorable a 
cicatricial ligament was formed which, in quite a 
number of instances, permitted a knuckle of in- 
testine to become wrapped about it and thus the 
result was peril, or even, death to the patient. The 
ligament frequently became attenuated and even 
broken, permitting the displacement to recur. 
A fixation operation is no longer considered as 
applicable to the child-bearing woman. 
Intraperitoneal shortening has been done by 
folding the round ligaments as in the Wylie, 
Baer, and Mann operations; by denuding the 
peritoneum over a portion of the ligament, and 
suturing this to a raw surface on the front of the 
uterus, the desmopycnosis of Palmer Dudley; by 
carrying a loop of each ligament through a slit 
Sutures Introduced for Ventrosuspension. 
-{Montgomery.) 
vantage over the previously named operation that 
it permitted treatment of diseased conditions 
and freeing the fixed organ. 
• The operation consists of an incision about 2 
inches long in the median line just above the 
symphysis through which the fundus uteri is 
brought up, and two sutures of silk, silkworm- 
gut or chromic catgut are passed through the fundus 
and peritoneum and a portion of the muscle on 
each side of the incision. The first stitch is on a 
line with the uterine cornua and the second, one- 
fourth of an inch behind it. The wound in the 
abdomen is closed by inserting a chromic catgut 
suture external to the aponeurosis on the right 
side of the upper angle of the wround, bringing it 
through the peritoneum and uniting the latter 
with a continuous stitch until the lower end is 
reached, when it is brought through the apon- 
eurosis on the left side; silkworm sutures are then 
inserted through all the tissues above the peri- 
toneum and the ends temporarily secured with 
hemostats when the aponeurosis is closed with the 
continuation of the peritoneal suture and tied at 
the upper angle of the wound. The tying of the 
silkworm sutures and the approximation of the 
skin edges between with plain catgut sutures 
completes the operation. 
Chromic catgut sutures are preferable for securing 
the uterus as they will ultimately be absorbed and 
if they become infected are not the cause of the 
formation of a sinus and of prolonged suppuration 
as would occur in the nonabsorbable suture. 
The portion of the fundus taken up in the 
Wylie's Operation for Shortening the Round Liga- 
ments within the Abdomen.-{Montgomery.) 
in the anterior uterine wall (Ries); by pushing a 
loop of each ligament through the broad ligament 
beneath the ovarian and securing it to the poste- 
rior uterine wall (Webster); or, by cutting the 
ligament near the uterus, tying the proximal end 
and securing the distal as in the Webster operation 
(Baldy); by resecting the ligament and uniting 
the divided ends, at the same time folding the UTERUS, RETRODISPLACEMENTS 
UTERUS, RETRODISPLACEMENTS 
anterior surface of the broad ligament (Bissell); 
by dragging a loop of each figament through the 
abdominal wall and securing it on the external 
surface of the aponeurosis (Gilliam); by carrying 
from the muscle, when the recti and pyramidales 
muscles are separated in the median line and the 
peritoneum opened vertically. This incision per- 
mits ready access to the pelvic structures as it is 
Mann's Operation for Intra-abdominal Shortening 
of Round Ligaments.-{.Montgomery.) 
this loop through an incision in the anterior leaflet 
of the peritoneum and securing it to the under 
surface of the rectus muscle (Simpson); or by 
carrying it outward between the layers of the 
First step in Montgomery's Modification of Gilliam's 
Operation. 
Dudley's Operation of Desmopycnosis. 
broad ligament and suturing it on the aponeurotic 
layer (Montgomery). Coffey depends on the 
cicatricial results of folding the peritoneum, 
especially in front of the uterus. 
Second step in Montgomery's Modification of Gilliam's 
Operation. 
Showing ligament fixed with hemostat while temporary 
ligature is carried beneath anterior leaflet of broad ligament 
with a Deschamps needle. 
Dudley's Operation Completed. 
A transverse crescent incision (Pfannenstiel) is 
made just above the symphysis, in the majority 
of cases in the hair line, through the skin, super- 
ficial fascia and the aponeurosis, the latter stripped 
directly over them. Diseased conditions of the 
tubes and ovaries are treated and adhesions 
separated. UTERUS, RETRODISPLACEMENTS 
UVULA, DISEASES 
A ligature is passed beneath the round ligament 
on either side, the ends of each ligature threaded 
into the eye of a sharp needle, while the round 
ligament is held tense in a pair of forceps, the 
threaded needle is carried through an opening in 
the anterior leaflet of the broad ligament between 
its layers until the reflexion of the peritoneum on 
the anterior wall is reached when it is plunged 
through and the ends of the ligature removed 
from the needle and temporarily secured by 
hemostat. After the opposite ligature is brought 
through, it is drawn taut and a pair of pointed 
scissors closed pushed through the opening made by 
the needle and the blades slightly separated, when 
to remove, and the deeper surfaces are maintained 
in firm apposition. 
This procedure has a number of advantages: 
there is no place for the intestines to become 
imprisoned and form unfortunate adhesions, the 
uterus is supported by ligaments capable of in- 
volution and evolution, the patient has the min- 
imum danger of subsequent hernia, and the scar is 
obscured by the regrowth of the pubic hair. 
As has been indicated, there is no operative pro- 
cedure which will serve in all cases. Where the dis- 
placement is accompanied by prolapse, it may be 
necessary to supplement the procedure by plastic 
operation on the anterior vaginal wall and the 
pelvic floor. Lacerations of the cervix should be 
repaired or the cervix amputated when the latter 
procedure is preferable. 
Intraperitoneal shortening of the uterosacral 
ligaments, or in case of their extreme attenuation, 
the quilting together of the peritoneum behind 
the cervix to lessen the depth of the retrouterine 
pouch may be necessary to maintain the uterus. 
UTERUS, RUPTURE OF.-See Postpartum 
Hemorrhage. 
UVA URSI (Bearberry).-The dried leaves of 
Arctostaphylos uva-ursi. It contains gallic and 
tannic acids, and 3 principles, arbutin, a bitter 
glucosid, neutral, crystalline, resolvable into 
glucose and hydroquinone; ericolin, bitter and 
amorphous; ursone, resinous, neutral, crystalline 
and tasteless. It is astringent, tonic, and diuretic. 
It was formerly much employed in calculous dis- 
orders of the bladder. It is given in chronic 
gonnorrhea or gleet, in pyelitis, and in cystitis. 
It turns the urine dark colored or black when taken 
in overdose. It has been used in incontinence of 
urine, in dysuria and strangury, and in uterine 
hemorrhages; also as a diuretic in cardiac dropsy. 
Dose, 10 grains to 1 dram in infusion or decoction. 
Arbutin is the glucosid. Dose, 5 to 15 grains. 
UVULA, DISEASES.-Inflammation of the uvula 
(uvulitis) often accompanies severe pharyngeal 
catarrh. The uvula appears red, swollen, and 
edematous, and often considerably lengthened. 
If the treatment for the associate pharyngeal 
catarrh does not relieve the condition, scarification 
may be practised. 
Elongation of the uvula may be due to chronic 
pharyngeal catarrh or to enlargement of the 
tonsils and associate conditions. If the elongated 
uvula comes in contact with the back of the tongue 
or with the mucous membrane of the larynx, there 
is a troublesome, tickling cough. The treatment 
for the causative conditions should be instituted, 
and if they fail, the organ must be amputated. 
See Palate, Pharyngitis (Chronic), Rhinitis 
(Chronic), Tonsils. 
the loop of the ligament is easily drawn through. 
Each loop is secured, by a few chromic catgut 
stitches. The wound is closed by a chromic cat- 
gut suture passed at its upper angle through 
muscle and peritoneum and afterward as a con- 
tinuous suture through the peritoneum only, until 
the lower angle is reached when it is brought out 
through the muscle and continued in the reverse 
direction through the muscle edges to the upper 
angle, where it is tied. Care is exercised not to 
produce such traction on this suture as to strangu- 
late the muscle. The aponeurosis is likewise 
closed with a continuous chromic catgut suture, 
while the skin is united by a continuous suture of 
plain catgut. Consequently, there are no sutures 
Completed Operation.-(Montgomery.) VACCINATION AND VACCINIA 
VACCINATION AND VACCINIA 
V 
VACCINATION AND VACCINIA (Cow-pox).- 
Vaccina is an eruptive disease of the cow, horse, 
camel, or other animal. Transferred to man by 
inoculation, it affords protection for varying periods 
against small-pox. This fact was discovered by 
Edward Jenner in 1798. 
Vaccination is performed by scratching the 
cuticle slightly and rubbing virus obtained from a 
calf, or child suffering from vaccinia into the scari- 
fications or abrasions. 
The etiology of cow-pox is unknown, though 
there is strong presumptive and experimental 
evidence that it is but a modified form of small- 
pox. Jenner believed this to be the case, and his 
observations have been confirmed by Gassner, 
Viborg, Theile, Ceely, Babcock, and many others, 
down to the present day, when King, Simpson, 
Leonhard, Voight, and Fisher claim success in 
producing vaccine of variolous origin; and while it 
is rather at variance with many known biologic 
factors, still the so-called spontaneous cow-pox 
almost invariably makes its appearance in the 
immediate neighborhood of genuine small-pox. 
The Virus.-Undoubtedly, the best form of 
vaccine virus to use is a glycerinated emulsion of 
the pulp of the vesicle from a healthy calf. Under 
the modern method of preparing, this is stored for 
from 4 to 6 weeks. During this time the glycerin 
destroys all extraneous organisms, while the organ- 
isms of vaccinia increase in power. Prepared in 
this form, the vaccine virus retains its activity for 
many months, and when used, produces the typical 
pock of vaccinia and is accompanied by very 
moderate local or constitutional disturbances and 
by only a slight febrile reaction. There is no 
doubt that the pronounced areola, swelling of the 
limb, tenderness of neighboring glands, and more 
or less grave depression occasionally seen, are the 
results of the accompanying organisms either con- 
tained in the vaccine or accidentally introduced 
subsequently; but as they were inseparable under 
the old methods of production, many laymen and 
some physicians still regard with doubt the success 
of a vaccination unaccompanied by "sore arms." 
Virus dried on points cannot be sterilized by any 
process known at the present time, and under the 
strictest precautions that can be observed it will 
be contaminated in the vast majority of cases; hence 
it is wise to use the glycerinated virus when obtain- 
able. Every physician appreciates the fact that 
it is difficult thoroughly to disinfect the human 
skin, for the reason that several varieties of organ- 
isms find their habitat upon its surface, in and 
under the superficial layers and also deep down in 
the hair follicles. In the cow this is more marked. 
It has been found by repeated culture tests that 
the normal serum, which in health is sterile, drawn 
from the scarifications on an animal before vaccina- 
tion, and after a most thorough antiseptic toilet, 
is in the vast majority of cases contaminated by a 
variety of organisms, most, if not all, of a non- 
pathogenic character; but one especially persistent 
streptococcus has certain cultural and micro- 
scopic characteristics leading to the belief that 
under proper stimulus it might be awakened into 
harmful activity. 
Deep pitting of the resulting cicatrix is probably 
caused by the action of some of these extraneous 
organisms. Thorough immunity can be conferred 
by subcuticular inoculation with sterile virus in 
which very little, if any, scar is left. 
Technic.-It is well to bear in mind, when vacci- 
nating a child, that the remaining scar is un- 
sightly, and on a girl's arm, in certain stations of 
life, a disfigurement to be avoided, if possible. 
This fact cannot be overlooked, and it is well to 
be guided by the mother's wishes, as there is no 
reason why some other portion of the body, such 
as the outer aspect of the thigh or the calf of the 
leg, should not be selected, provided the parts 
where the blood-vessels are thinly covered or where 
there are large masses of lymphatics are avoided. 
In the absence of such reason or in the case of a 
boy the classic site, above the insertion of the 
deltoid on either arm, possesses advantages be- 
sides that of custom. This area is readily access- 
ible for operation and inspection, and can be pro- 
tected from violence. 
Vaccination is usually performed during the first 
4 months of life, and, if unsuccessful, should be 
repeated at intervals, immunity, so called, being 
rare; the failure, in a vast majority of cases, is due 
to poor or inert virus. 
Having selected a site, cleanse the surface with 
alcohol or ether, applied with a piece of absorbent 
cotton; then wash thoroughly with boiled water, 
or, if there is reason to suspect infection of any 
sort-such as suppurating wounds, contagious dis- 
eases, etc., in the same family or house-it is well 
to use a solution of bichlorid of mercury 1 : 5000 
or 5 percent phenol solution, being careful to wash 
away every trace of the antiseptic with boiled 
water; otherwise, the vaccination will probably be 
unsuccessful. It is rarely necessary to use the 
stronger antiseptics in children or adults of cleanly 
habits and surroundings. 
Grasp the limb with the left hand, stretching 
the skin between the index-finger and the thumb, 
blanching it, and scarify one or two spots by cross- 
hatching, thus bringing to the surface a little 
serum, each spot to be about 1/3 of an inch square, 
and to be separated by an inch of healthy skin in 
order to prevent coalescence of the vesicles if more 
than one scarification is made. Bear in mind that 
one typical vesicle the size of a pea affords as much 
and as thorough protection as will a dozen larger 
ones. However, it is well, at times, to perform 
multiple vaccinations on a child whose parents are VACCINE THERAPY 
VACCINE THERAPY 
at all reluctant and not likely to return in case the 
primary vaccination fails, the larger number of 
spots lessening the danger, as one is almost certain 
to introduce the active principle of vaccinia into 
one or more of the spots. Care and thoroughness, 
if virus is active, will insure success in single-spot 
primary vaccinations. 
An ordinary sewing-needle is by all means the 
best kind of scarifier. It can be obtained in every 
house, and is furnished by some of the producers 
with each vaccination. It is readily sterilized by 
passing it through the flame of a match, candle, 
gas, or other light. It will tear rather than cut 
the cutaneous vessels and absorbents, doing away 
with bleeding, and by slightly bruising the tissues, 
prepares a more favorable soil for the vaccine or- 
ganism to grow upon. If virus dried on ivory 
points is used, the point itself makes a good 
scarifier. The physician should never use a pocket 
lance or scarifier unless it can be, and is, thoroughly 
sterilized before each vaccination. And he should 
not overlook the fact that all these precautions 
are useless if his own hands are not surgically clean. 
The virus selected is rubbed into the scarification, 
either by reversing the needle and using the eye, 
or by, what is preferred, a little splint of hard wood 
(an orange-wood toothpick with one end spade- 
shaped answers perfectly). Rub the virus well 
into the scarification, and keep uncovered until 
dry. It is well to protect the forming scab, 
especially in young children, by some form of 
shield. Many, however, prefer a sterile gauze 
compress fastened by adhesive plaster. It is im- 
portant to protect the crust or scab from violence, 
as it undoubtedly is the best protective, unless it 
becomes very purulent. In this case it should be 
removed with a sharp curette and treated as an 
infected wound. 
Hutchin has suggested a method which is 
especially valuable in children: After the site 
selected is cleansed, a bit of cotton wet with liquor 
potassse is applied for 2 or 3 minutes. After its 
removal, the site is dried and gently rubbed with 
moist cotton. Thus the epidermis is readily 
removed and the vaccine may be applied and 
allowed to dry. 
In normal vaccination there is a gradual increase 
of redness at the point of inoculation, and on the 
third day there is a slight shotty feeling, followed 
by small vesicles on the fourth and more pronounced 
vesicular on the following day, the vesicles be- 
coming confluent on the seventh day, when the 
temperature reaches its maximum. About the 
eleventh or twelfth day the areola should disappear 
and the scab begin to dry. This continues until 
about the twenty-first day, when it becomes 
detached, leaving a healthy, cicatrized base. See 
also Small-pox. 
VACCINE THERAPY.-Vaccine or, better, 
bacterin therapy is a method of treating diseases 
due to bacterial action, based on the principle that 
the injection of killed bacteria increases the 
bactericidal power of the body by stimulating the 
production of antibodies. The immunity thus 
produced, which is of variable duration, is an 
active immunity, in contradistinction to the passive 
immunity which follows the administration of 
antitoxic sera. The antibodies are present in the 
tissues of the body generally, in exudates and 
transudates, as well as in the blood plasma. The 
term opsonins was employed by Wright to describe 
these substances, because they have the property 
of preparing or sensitizing bacteria for ingestion 
by the phagocytes (phagocytosis), and the de- 
termination of the opsonic index is merely a method 
of ascertaining the phase of active immunity of 
an individual against a given bacterial infection. 
Opsonins, however, are not the only antibodies 
produced by the injection of antigens (vaccines or 
bacterins), or by the entrance of pathogenic 
bacteria into the body in the ordinary genesis of 
"disease," and the opsonic index is therefore not 
an absolutely trustworthy criterion of the in- 
dividual's resistance or immunity. In a general 
way the opsonic index and the clinical symptoms 
run an approximately parallel course, and for this 
reason, as well as because the technic of opsonin 
determinations is difficult and time-consuming, 
besides not being altogether reliable, it is generally 
held that clinical control is a more satisfactory 
guide in the management of the case with regard 
to dosage, intervals between injections, etc. It 
does not suffice, however, to observe such obvious 
phenomena as rise of temperature, variations in 
the leukocyte count, changes in weight, and local 
manifestations in the disease focus or at the point 
of inoculation; such minor deviations from the 
normal as malaise, slight indisposition to work, 
loss of appetite, and the like must receive careful 
attention in the intelligent application of bacterin 
therapy. In some instances, when there is an 
absolute lack of subjective or objective signs, the 
opsonic index is distinctly helpful, as, when there 
is fever; when the lesion is deep-seated, as a 
pyelitis or pyelonephritis, or a suppurative otitis 
media; in acne and furunculosis, when the lesions 
have disappeared and it is important to know how 
long the treatment should be continued. 
Determination of the Opsonic Index.--The op- 
sonic index is the ratio of the phagocytic activity of 
an individual'^ leukocytes compared to that of the 
leukocytes in a normal or control serum. Thus, 
if 100 leukocytes in the serum to be investigated 
are found to contain 850 bacteria, while the same 
number of leukocytes with normal serum ingest 
1000 bacteria, the patient's opsonic index is 
equivalent to 0.85 (850 : 1000 :: x : 1). The 
technic is as follows: A few drops of the patient's 
blood and of the control blood are collected in two 
glass tubes and allowed to coagulate in order to 
separate the serum. Ten to fifteen drops of nor- 
mal blood are then allowed to fall into a normal 
salt solution containing 11/2 percent sodium 
citrate. This prevents clotting, and the corpuscles 
are thoroughly washed by centrifugation in 
normal salt solution until they are absolutely 
neutral and free from serum. The leukocytes, 
being lighter than the red cells, float on top and 
are transferred with a pipette to another tube. A 
culture of the given bacterium is washed in normal 
salt solution and centrifuged, so that the super- 
natant suspension or emulsion contains only VACCINE THERAPY 
VACCINE THERAPY 
individual bacteria in not too great concentration. 
Two opsonizing pipettes, P (patient) and C (con- 
trol), about the caliber of a large hatpin, are 
marked at a distance of about 1/2 or 3/4 of an 
inch and, by means of a rubber bulb, equal 
quantities of patient's serum, bacterial suspension, 
and washed leukocytes are drawn up and mixed 
in the pipette P, and the same performance re- 
peated with pipette C, except that control serum 
instead of patient's serum is mixed with bacteria 
and leukocytes. The tips are then sealed in the 
flame and the two pipettes incubated for a few 
minutes in a thermostat at 37° C. (98.6° F.), 
shaking the tubes at short intervals during the 
incubation to insure a uniform mixture of bacteria, 
serum and leukocytes. Smears are then made 
from the pipettes, fixed and stained. The number 
of bacteria contained in at least 100 phagocytes 
should be counted and the index determined as 
explained; or Simon's method of determining the 
ratio of the number of phagodyting leukocytes, 
which is simpler and quite as reliable as the method 
of Wright, may be used. If the index is less than 
1, the patient is said to be in the "negative phase," 
and it is the aim in bacterin therapy to cause the 
index to rise into the "positive phase," and main- 
tain it there. 
Preparation of Bacterins.-The process consists 
in preparing an emulsion of bacterial culture (24 
hour) in normal salt solution, adding 0.5 percent 
phenol, and agitating the emulsion in a mechanical 
shaker for from 1/2 to 1 hour to insure uniformity. 
The emulsion is then standardized, by means of 
an ordinary hemocytometer, to contain from 
100,000,000 to 1000,000,000 bacteria per cubic 
centimeter. Finally the bacteria are killed by 
exposure in a water bath to a temperature of 60° 
to 65° C. (140° to 150° F.) for 1/2 to 1 hour. The 
consensus of opinion is in favor of "autogenous" 
bacterins whenever it is feasible to cultivate the 
bacterium in question, but good results are re- 
ported from the use of "stock" preparations, 
especially poly valent bacterins, representing several 
strains of the bacterium. It is to be remembered 
also that the bacterial flora in some cases of 
suppuration has a tendency to vary from time to 
time; in such cases the pus should be cultivated and 
recultivated at intervals, and only an autogenous 
bacterin employed. Tuberculous disease of bones 
and joints calls for accurate bacterial diagnosis to 
establish the identity of the pyogenic microorgan- 
ism, the bacterin of which is then associated in 
the treatment with tuberculin. Some bacteria do 
not lend themselves readily to cultivation, and 
autogenous bacterins of such organisms are there- 
fore not obtainable; the principal examples of this 
type are the tubercle bacillus and the gonococcus. 
Administration and Dosage.-Bacterins are to 
be injected subcutaneously, the site of injection 
being a matter of choice or convenience. The 
forearm is the region usually selected. Ordinary 
aseptic precautions as in the case of all hypodermic 
injections, are to be observed. The size of the 
dose is determined in part empirically, in part by 
the nature of the affection, whether acute or 
chronic, the presence of fever, the patient's 
resistance and the individual bacterin to be used. 
Thomas' golden rule is " the sicker the patient the 
smaller the dose." In acute infections, if bacterins 
are used at all, the dose must Be very small at 
first and increased with great caution; while in 
local, chronic lesions the treatment may be pushed 
more rapidly. The conventional initial dose, 
moreover, varies with different bacteria. The 
intervals between injections may vary from 5 days 
to a week or more; there can be no hard and fast 
rule either with regard to intervals between in- 
oculations or the size of the dose, which must be 
determined in every individual case by a study of 
the clinical symptoms or, possibly, the opsonic 
index. 
Certain accessory procedures should be men- 
tioned in connection with bacterin therapy, partic- 
ularly in refractory cases-old chronic sinuses, old 
inflammatory exudates that have become walled 
off, and the like. The blood may be plentifully 
supplied with antibodies in such cases, but unable 
to gain access to the disease focus. Bier's method 
of hyperemia, local application of heat, massage, 
incisions, the internal administration of citric acid 
to diminish the viscosity of the blood, or flushing 
the diseased area with 0.5 percent sodium citrate 
to promote dissolution of the fibrin in the lymph- 
spaces and 5 percent salt or 10 percent sugar 
solution to favor osmosis of the blood-lymph, are 
some of the measures recommended. 
Indications and Contraindications.-In the most 
general way it may be stated that bacterins are 
most effective in localized, suppurating lesions of 
the skin and mucous membranes, such as abscesses 
in the subcutaneous tissues, acne, furunculosis, 
sycosis and carbuncles, and ocular lesions-kera- 
titis, corneal ulcer, conjunctivitis, iritis and 
uveitis. Chronic conditions respond more readily 
than acute infections. Bacterial inoculations are 
useful also in certain deep-seated affections, chronic 
sinuses after celiotomies or leading to a kidney the 
seat of pyelonephritis; certain affections of the 
urogenital system-cystitis, prostatitis, vulvo- 
vaginitis of children, pyelitis and the like; gonor- 
rheal arthritis; chronic osteomyelitis and osteo- 
periostitis whether of pyogenic or tuberculous 
origin. On the other hand, bacterin therapy is 
postively contraindicated in all diffuse infections 
characterized by septicemia or pyemia, and in all 
severe acute infections-pneumonia, typhoid 
fever-when the body is already overwhelmed by 
the bacterial invasion, and whenever there is a 
suspicion of bacteremia. 
Space does not permit, nor is it necessary, to 
enumerate individually all the pathogenic bacteria 
that lend themselves to the method of bacterin 
therapy. Tuberculin, which is in effect a bacterin, 
will be discussed at length, however, and the most 
essential points in regard to the employment of 
other bacterins which have been subjected to a 
practical test will be briefly touched upon. 
Tuberculin. 
Koch's original product represented a " glycerin 
extract of pure cultures of the tubercle bacillus, 
containing an active substance insoluble in alcohol, VACCINE THERAPY 
VACCINE THERAPY 
and all the products of the growth of the bacillus 
soluble in 50 percent glycerin." This crude 
tuberculin has now been supplanted by improved 
preparations in human medicine. 
Preparation.-The tuberculin in current use 
represents either (1) a filtered extract of bouillon 
culture, containing, therefore, only soluble prod- 
ucts of the bacilli; or (2) an emulsion which con- 
tains all or the greater portion of the bacterial 
bodies themselves. Old Tuberculin ("O. T." 
Alttuberkulin), is the chief representative of the 
first class, to which also belongs Purified Tuber- 
culin {Tuberculin Purum, Endotin). The second 
class inculdes New Tuberculin (Tuberculin R., "T. 
R.," meaning "residual tuberculin" because it is 
the solid residue of the first centrifugation) and 
Bacillus Emulsion ( "B. E.," "Bazillenemulsion"). 
These may be regarded as true vaccines or bacterins; 
that is, suspensions of killed bacteria in physiologic 
salt solution, or other suitable medium.* 
New Tuberculin, "T. R." Synonyms.-Tuber- 
kulin, Rest, Tubercle Bacilli Residue, "T. R." 
{Ruckstand')', Neutuberkulin Koch, "T. R.," 
Tuberculin "T. R." 
A glycerinated saline suspension of the major 
portion of the sediment remaining after centrif- 
ugating desiccated and pulverized tubercle bacilli, 
which have been triturated with physiologic salt 
solution. 
Preparation.-A virulent culture of tubercle 
bacilli is dried in vacuo and finely pulverized. 
The finely powdered bacilli are then triturated 
with a definite quantity of physiologic salt solu- 
tion, centrifuged, and the supernatant, opales- 
cent fluid containing extractives and fatty sub- 
stances mixed with comminuted bacilli (known 
as Tuberkulin Oberer, "T. O.") is removed and 
discarded. The sediment is again triturated with 
another portion of physiologic salt solution and 
centrifuged, and the process is repeated until 
almost no sediment remains. The centrifugates 
are then mixed and sufficient glycerin added to 
insure the presence of 20 percent in the finished 
product. The finished product is then standard- 
ized, so that each cubic centimeter represents the 
active substance found in 10 mgm. of the original 
dried tubercle bacilli. 
Initial maximal dose: One-ten-thousandth of a 
milligram (0.0001 mgm.). 
Purified Tuberculin. Synonyms.-Tuberculinum 
Purum, "T. P."-Endotin. The purified extract 
of a filtered culture of (human) tubercle bacilli in 
50 percent glycerin. 
Preparation.-Koch's old tuberculin is treated 
with alcohol, ether, chloroform and xylol in order 
to remove the deuteroalbumoses present. Endotin 
is supplied in packages containing 7 ampoules each, 
progressively graded in strength, which are in- 
tended to represent one course of treatment. 
Initial maximal dose: One-fiftieth of a milligram 
(0.02 mgm.), by hypodermic injection. 
Tubercle Bacillus Emulsion. Synonyms.-New 
Tuberculin, " B. E.," Bacillary emulsion; Neutu- 
berkulin, Bazillenemulsion. A glycerinated sus- 
pension of devitalized tubercle bacilli. 
Preparations.-A virulent culture of tubercle 
bacilli is dried in vacuo, and finely powdered in 
the same manner as in the preparation of "T. R." 
The finely powdered bacilli are then mixed with 
equal parts of water and glycerin. The resulting 
suspension should contain 5 mgm. of dried sub- 
stance in 1 c.c. 
Initial maximal dose: One-ten-thousandth of a 
milligram (00.0001 mgm.). 
Dixon's Tubercle Bacilli Extract (Fluid of Dixon). 
-An extract of tubercle bacilli dissolved in normal 
saline solution, marketed in syringes containing 
the extract from 1 mgm. of bacilli. 
The standard therapeutic dose is a weekly injec- 
tion of the contents of 1 syringe, to be reduced in 
amount and frequency if the patient shows signs 
of reaction. 
Dixon's Suspension of Dead Tubercle Bacilli.- 
A suspension in normal saline solution of killed 
tubercle bacilli, which have been decreased by 
prolonged treatment with alcohol and ether. 
Tuberculin Preparations. 
Old Tuberculin, "O. T."-Synonyms: Kochs' 
tuberculin, tuberculin Koch, original tuberculin; 
Alttuberkulin, Alttuberkulin Koch. 
A filtered glycerin extract of tubercle bacilli. 
Old tuberculin is a clear, syrupy, amber-colored 
fluid, of a peculiar, characteristic odor and sweetish 
taste. 
Preparation.-A bouillon culture of tubercle 
bacilli, 6 to 8 weeks old and containing 5 percent of 
glycerin, is evaporated and concentrated to 1/10 
its volume (preferably in a water bath to avoid 
high heat). The devitalized germs from which the 
toxic substances have thus been extracted are 
then removed by filtration through porcelain. 
The finished product contains 50 percent of glycerin 
and should be diluted at least two-thirds when 
used for hypodermic injection. 
Initial Maximal Dose.-One-thousandth of a 
milligram (0.001 mgm.) hypodermically. (See 
"Tuberculin Serial Dilutions," and "Abrasion," 
"Tuberculin for Diagnostic Purposes"). 
Tuberculin Filtrate. Synonyms.-Tuberculin 
Denys, " B. F.," Bouillon Filtrate; Bouillon filtr^, 
Denys; Denys Tuberkulin. 
The bouillon from cultures on which tubercle 
bacilli of the human type have been grown to 
maturity (5 to 6 weeks), freed from germs by 
filtration through porcelain. This preparation 
differs essentially from " old " tuberculin in the fact 
that no heat is used in its manufacture. 
Initial Maximal Dose.-One-thousandth of a 
milligram (0.001 mgm.). (See Tuberculin, Serial 
Dilutions.) 
* "T. O." is sometimes used instead of "O. T." to design te 
"Old" or "Original" Tuberculin. This is an error. "T. O." 
means Tuberkulin Oberer, a by-product in making New 
Tuberculin, "T. R.". 
"Tuberculin Koch" is claimed by a German manufacturer 
as a trade-mark, and when thus specified, pharmacists may 
feel under obligation to dispense only the controlled prepara- 
tion. Hence the term is avoided in the text. The same 
house also claims the word "Tuberculin" as private property. 
This claim, however, is scarely to be conceded by scientific 
writers. 
Some manufacturers furnish tuberculin of bovine, as well 
as human type. VACCINE THERAPY 
This is marketed in syringes containing 1/1000 
mgm. of bacilli, which is the standard therapeutic 
dose. 
Spengler's Perlsucht ("P. T. O.") is prepared 
from the bacillus of "pearl disease," which is a 
true bovine tuberculosis. The preparation is the 
same as that of old tuberculin. According to 
Spengler, fever and mixed infection do not con- 
traindicate its use, since it is but slightly toxic 
for human beings. • 
Initial maximal dose: One-thousandth of a milli- 
gram (0.001 mgm.) by hypodermic injection. 
and blood. A scarlatiniform rash appears upon 
the neck and chest. The reaction begins from 
4 to 5 hours after the injection and lasts about 
15 hours. Patients with recent and rapidly 
progressing lesions exhibit the most pronounced 
disturbances; in chronic, and especially in fibroid 
cases, the phenomena are comparatively mild. 
With the original Koch lymph reactions were 
also observed in lepers, in patients suffering from 
lupus, and in syphilitics with secondary lesions. 
Local Reaction.-A lupous lesion of the face, 
some hours after an injection of tuberculin, 
exhibits an increase of redness and inflammation, 
which extends to new areas during the reactive 
febrile period. The lupous tissue becomes brown 
and finally necrotic. As the temperature falls, 
the swelling of the affected tissues diminishes little 
by little, and disappears in 2 or 3 days. During 
this time the lesions are covered with crusts, 
formed by the exuded serum which has dried in 
the air. These come away in the course of 2 or 3 
weeks, leaving a smooth, shining, red cicatrix. 
Internal Local Reaction.-Tuberculin appears to 
excite irritation, inflammation and necrosis in 
tuberculous tissue, and this reaction, if severe, 
may prove dangerous in certain localities, 
especially the larynx. In early cases of pulmonary 
tuberculosis the primary irritation may be followed 
by absorption or removal by expectoration of the 
tuberculous tissue, and stimulation of reparative 
processes. Clinically the reaction manifests itself 
by temporary increase in the local signs and 
aggravation of the cough. It is generally believed 
that the tuberculin reaction is accompanied by 
the migration of a large number of leukocytes, 
which attack the necrotic tissue elements as well 
as the bacilli themselves and remove them through 
the circulation. It also excites the production of 
antibodies, which probably play some part in the 
destructive or reparative changes in foci of 
tuberculous tissue. The temporary tolerance 
induced by the injection of progressively increasing 
doses of tuberculin is an antitoxic reaction. 
Opsonic Reaction.-An injection of tuberculin 
is followed by the same series of changes in the 
opsonic index as that observed after the injection 
of bacterial vaccines in general. The primary 
negative phase is succeeded after a variable interval, 
depending upon the individual's initial index and 
the quantity of tuberculin injected, by a positive 
phase or period of increased opsonin production, 
induced by more active phagocytosis. 
There are at present four recognized methods 
of tuberculin diagnosis: 
1. The Subcutaneous Test (Koch), applied by 
hypodermic injection of old tuberculin. In 
tuberculous subjects it excites a reaction marked 
by (1) constitutional, usually febrile disturbances, 
and (2) the development or increased distinctness 
of local symptoms. The method of application is 
as follows: 
The temperature and pulse rate of the patient to 
be investigated are carefully noted for from 4 to 7 
days, after which, if these are normal or only 
slightly elevated, an initial injection of0.5mgm. 
of old tuberculin is given. If no reaction follows 
VACCINE THERAPY 
Tuberculin as a therapeutic agent, after the 
early unsuccessful and even disastrous resuits 
which followed its use in pulmonary tuberculolss, 
was practically abandoned, and even the diagnostic 
use of tuberculin gradually fell into disrepute until, 
in quite recent years, the announcement by Wolff- 
Eisner and Calmette of a new method of applying 
this specific test, followed by several additional 
methods proposed by other investigators, revived 
the interest in tuberculin diagnosis. 
Tuberculin Reaction.-When a sufficiently large 
dose of tuberculin-from 0.5 to 2.5 mgm. of old 
tuberculin-is injected subcutaneously into a 
normal, non-tuberculous individual, certain con- 
stitutional and local effects are observed, which 
constitute a tuberculin reaction. 
From 3 to 4 hours after the injection general 
lassitude, with weakness and numbness of the 
extremities and more or less desire to cough, 
begins to manifest itself and rapidly increases in 
degree to decided oppression or prostration. Then 
follows a chill, which is characteristic of the tuber- 
culin reaction and lasts about an hour. The tem- 
perature at the same time rises and, at the end of 
12 hours, reaches about 103° F. (39.6 C.). In- 
creased frequency of pulse and respiration, and 
in many cases nausea and vomiting, accompany 
the pyrexia. After some 12 hours longer, the 
temperature begins to fall, the constitutional 
symptoms subside, and by the following day 
normal conditions are, in the main, restored. 
The numbness and aching of the limbs and the 
general depression may, however, persist for a 
few days. The site of injection is slightly reddened 
and painful, but abscess formation is extremely 
rare. 
To produce these effects in a normal, robust 
adult, a dose of at least 10 mgm. of old tuber- 
culin is usually necessary. Nearly every one in- 
jected with this dose, however, experiences more 
or less pain in the limbs and lassitude lasting 
for some time, and usually a slight elevation of 
temperature, from 0.5° to 1° F. (0.3° to 0.6° C.). 
Reaction in the Tuberculous.-In tuberculous 
subjects the injection of a very much smaller 
quantity-0.01 mgm. or less-of old tuberculin 
suffices to bring about the above described reaction. 
The temperature reaches 105° F. or even higher, 
and the rise is usually preceded by rigor; the pain 
in the limbs is severe; nausea and vomiting are 
frequently present, and sometimes accompanied 
by slight jaundice; the urine may contain albumin 
Diagnostic Use of Tuberculin. VACCINE THERAPY 
VACCINE THERAPY 
this in from 3 to 4 days, the same dose is repeated, 
without increase, particularly if any symptoms 
indicative of a mild reaction have occurred. If 
the temperature shows any irregularities, a longer 
interval is allowed to elapse and the same dose 
repeated a third time. Usually, however, in the 
absence of a reaction, the dose at the second injec- 
tion is increased to 1.25 mgm. This may be re- 
peated if two or three days again elapse without 
reaction; or the dose may be increased to 2.5 mgm., 
which is to be regarded as the maximal dose for 
diagnostic purposes. If reaction is still wanting, 
however, the maximal dose may be repeated. 
The importance, at each stage of the test, of 
repeating the same dose before increasing the 
quantity is to be emphasized. Often a merely 
suggestive reaction after the first injection is 
followed by severe symptoms after a second dose 
of the same strength. 
A rise in temperature of 1° F. (0.5° C.) above the 
previous maximum is accepted as a positive sign; 
but a less marked rise is not necessarily negative. 
General constitutional disturbance and increased 
activity of local phenomena-for example, the 
development of rales where they were previously 
absent-are also to be considered positive, even 
when the temperature is but slightly augmented. 
In suitable cases there is no danger in the test 
as outlined, if the patient is kept in bed until the 
disturbances of reaction have subsided, or a nega- 
tive result is clearly evident. A few days of rest 
usually suffice. 
Contraindications.-The method should not be 
employed in the presence of nephritis or tubercu- 
losis of the kidneys, when there have been recent 
hemorrhages. It is also to be avoided in ill- 
nourished individuals and during convalescence 
from any acute infection. 
Prognostic Value.-There appears to be a direct 
relation between the degree of reaction and the 
severity of the tuberculosis infection. As a rule, 
marked reaction is a relatively favorable sign, and 
sluggish reaction is relatively unfavorable. Thus 
the disturbance is greater in recent infections than 
in cases of long standing. In advanced tubercu- 
losis the test may prove negative, indicating that 
the patient's resisting powers are exhausted, and 
the prognosis in such cases is correspondingly grave. 
2. The Ophthalmic Reaction (Calmette; Wolff- 
Eisner).-In this method a drop of 1 to 5 percent 
old tuberculin solution is instilled into the conjunc- 
tival sac. The reaction, which appears about 8 
hours later, consists in hyperemia and redness of 
the caruncle or of the entire palpebral and orbital 
conjunctiva, with a slight fibrinous or fibrino- 
serous, grayish exudate. Reaction is not infre- 
quently delayed for 48 hours and remains well- 
defined for 2 or 3 days. Three grades are recog- 
nized: (1) Moderate redness of the caruncle and 
conjunctiva; (2) more intense hyperemia of the 
conjunctiva, with fibrinous exudation; (3) deep 
injection of the entire conjunctiva and chemosis, 
with swelling of the external tissues. 
The ophthalmic test is not without danger and 
has practically been superseded by the safer 
cutaneous methods. Special contraindications 
are the presence of ocular tuberculosis or a 
history of tuberculous keratitis, phlyctenular 
conjunctivitis or, according to most authorities, 
any form of conjunctivitis. 
3. The Cutaneous Test (von Pirquet).-See 
Tuberculin (Cutaneous Reaction). 
(4) The Inunction Test (Moro).-A small 
quantity of old tuberculin undiluted or in a 50 
percent solution (old tuberculin 5 c.c., anhydrous 
wool fat 5 gm.) is rubbed vigorously into the skin 
for about half a minute, and the area covered with 
a protective dressing to permit absorption. The 
finger used in making the inunction should be 
protected with a rubber cot, or a fiat glass stopper 
may be used for the rubbing. The crop of papules 
which results in a positive case is quite character- 
istic. They appear in from 6 to 24 hours and per- 
sist for 2 or 3 days. An area equal to about 4 or 5 
square inches is selected on the chest or abdomen 
and, for the purpose of control, a similar area is 
subjected to the same treatment with petrolatum 
or other neutral substance. 
Of the various methods of tuberculin diagnosis 
the cutaneous test after von Pirquet appears to 
be the most satisfactory and is now generally 
adopted as a routine diagnostic procedure in 
clinical work. Opinions in regard to the compara- 
tive value and the significance of the various 
tuberculin tests are constantly changing, and 
dogmatic statement is, therefore, as yet premature. 
The percentage of positive reactions to the cutane- 
ous test (using 20 to 100 percent tuberculin) 
obtained among clinically non tuberculous sub- 
jects is undeniably high, and the test is most 
valuable when negative. For this reason it is now 
advised that weaker solutions be employed for 
the test. The ophthalmic test is not entirely free 
from danger and for a time it fell into disuse, but 
has recently been again recommended by very 
competent investigators. Its greater delicacy is 
generally conceded, the percentage of positive 
reactions among nontuberculous subjects not 
exceeding 2 percent when a solution of from 1 to 5 
percent strength is employed. 
Therapeutic Use of Tuberculin. 
Judgment must be used in the selection of cases 
for tuberculin therapy, and the patient must be 
under strict observation and control during the 
entire course of the treatment. The cardinal rule 
is to avoid bringing about a pronounced reaction 
and, if a reaction occurs in spite of careful dosage, 
to interrupt the treatment and when the injections 
are resumed, to begin again with a smaller dose 
than the last one injected. In this way the 
patient is gradually carried along until tolerance 
to a considerable dose is established, or, in other 
words, until he has developed a measure of active 
immunity to the toxin of the tubercle bacillus. It 
is ever to be borne in mind also, that the specific 
treatment of tuberculosis is not an exclusive or 
even a principal method, but an adjuvant to the 
classical treatment by fresh air, generous feeding, 
and the proper alternation of rest and suitable 
exercise. Local treatment, both surgical and 
medical, and internal medication are also to be VACCINE THERAPY 
VACCINE THERAPY 
employed, according to indications in the individ- 
ual case. See Tuberculosis (Pulmonary). 
In pulmonary tuberculosis the most rigorous 
selection of cases must be exercised in order to 
achieve even a small measure of success; and 
to employ the treatment indiscriminately is to 
court disaster. As the first marked successes 
were obtained by the laryngologists, the oph- 
thalmologists and the dermatologists, they give 
us a clue to the main indications that must be 
observed in the selection of pulmonary cases- 
namely, localization, and absence of general in- 
toxication. The most suitable cases are those free 
from mixed infection; in which the temperature is 
normal, or at most does not rise above (37.0° C.) 
100° F., in which resistance and nutrition are good, 
and there is a tendency to encapsulation of the 
pulmonary lesion. The more chronic the type of 
disease, whether the case be incipient or advanced, 
the clearer the indication for tuberculin treatment. 
Acute cases, incipient cases with rapid onset and 
active symptoms, and cases with extensive lesions 
or with intestinal and other severe complications, 
are as a rule unsuitable for tuberculin therapy, and 
should be treated by rest, fresh air, liberal feeding, 
and appropriate medication, without the specific. 
If, after a certain degree of improvement has been 
reached by these means, there is a tendency to the 
arrest of progress; or if a patient with early cir- 
cumscribed lesions, improving under nonspecific 
management, suddenly shows a tendency to retro- 
gression-and then, even if there be slight fever-• 
the administration of tuberculin may revive the 
failing powers of resistance, may stimulate the 
organism to produce fresh antibodies, and may 
start the patient again on the road to recovery. 
In this way tuberculin sometimes proves a valuable 
adjuvant to general hygienic treatment; and when, 
for practical reasons, the patient cannot be given 
the advantages of suitable food and environment, 
it may even in a measure take the place of climatic 
change and dietetic regulation. 
Contraindications.-Moderate evening pyrexia, 
rapid pulse, slight dyspnea, and even hemoptysis, 
unless severe, while calling for special care in the 
administration of tuberculin, do not absolutely 
contraindicate its use. Pregnant women may 
receive the treatment. But whenever the general 
nutrition is poor; when the temperature rarely goes 
below 99.5° or 100° F., and especially when the 
physical signs indicate extensive softening and 
ulceration of pulmonary tissue, tuberculin therapy 
should not be attempted. Nephritis, except 
when it can be positively shown to be tuberculous, 
is generally considered a contraindication. In 
all cases of generalized pulmonary and intestinal 
tuberculosis, and in the miliary form, the use of 
tuberculin is, of course, out of the question. 
Gonococcus (Micrococcus Gonorrhese).-As cul- 
tivation is difficult, stock bacterins, of which there 
are a number on the market, are generally em- 
ployed. There is great diversity of opinion as 
to the efficacy of gonococcus bacterin in the various 
primary and secondary manifestations of this 
infection. It is usually said to be of undoubted 
value in acute vulvovaginitis of children, in doses 
of 5,000,000 also in acute, subacute, and chronic 
gonorrheal arthritis and possibly gonorrheal exos- 
toses. For adults the dose in these conditions 
ranges from 50,000,000 to 1,000,000,000. 
Staphylococcus Pyogenes (Micrococcus Albus, 
Aureus, Citreus).-Isolated from acne vulgaris, 
furuncles and carbuncles, superficial abscesses, 
sinuses and postoperative infected wounds, and 
suppurative bone and gland disease complicatin 
tuberculosis. Either autogenous or a good poly- 
valent stock bacterin should be selected. The 
dose ranges from 50,000,000 to 500,000,000. 
Bacillus Acnes.-Isolated from acne lesions of 
the mild papular type, in which it is said to be 
effective in doses of 5,000,000 to 50,000,000 bacilli. 
Stock bacterin can be obtained either of the acne 
bacillus alone or in combination with a polyvalent 
staphylococcus bacterin. 
Streptococcus Pyogenes.-This is the most 
heterogeneous of all the pyogenic bacteria, which 
probably accounts for the general failure of anti- 
streptococcic serum and of stock bacterins. 
Whenever possible, autogenous bacterins should be 
prepared. It is recommended in localized infec- 
tions due to streptococcus pyogenes-postopera- 
tive infected wounds and sinuses, etc., also in 
acute and recurrent erysipelas, and in subacute or 
chronic endocarditis; dose, 25,000,000 to 100,000,- 
000. The use of streptococcus bacterin in puer- 
peral septicemia, pyemia, and acute malignant 
endocarditis has also been advised, but the 
expediency of bacterial inoculations in any acute 
generalized bacteremia is open to grave doubt. 
The dose in acute infections should be small, from 
5,000,000 to 25,000,000. 
The bacterins prepared from streptococcus and 
other pyogenic organisms, as well as from certain 
other bacteria like streptococcus mucosus, which are 
found chiefly in the conjunctival sac, have been 
used successfully in various suppurative conditions 
affecting the ocular tissues. Reference to these 
bacterins will be found under special headings. 
Bacillus Coli Communis.-See Colon Bacillus 
Infection. 
Bacillus Typhosus.-Typhoid bacterin is useful 
chiefly for prophylactic inoculation, as the records 
of the English army have convincingly shown. 
The initial immunizing dose is 500,000,000, fol- 
lowed after ten days by a second injection of 100,- 
000,000 and usually a third after an equal interval. 
The therapeutic dose is smaller, from 50,000,000 to 
200,000,000 (acute general infection) and is rec- 
ommended more particularly in relapsing cases 
and for the treatment of typhoid carriers. 
Pneumococcus.-Special indications for the use 
of pneumobacterin are found in postpneumonic 
empyema after evacuation of the abscess, in 
pyorrhea alvbolaris in conjunction with other 
bacterins, and in corneal ulcer (ulcus serpens 
cornese). Encouraging results are reported in 
this ocular complication. It may be tried in any 
case of frank lobar pneumonia without bacteremia. 
Reports as to the efficacy of pneumobacterin in 
the treatment of the primary infection are very 
contradictory. The dose is from 25,000,000 to 
100,000,000. VAGINA, HEMORRHAGE 
Other bacterins that have been used with more 
or less success are those prepared from micrococcus 
neoformans, a variety of staphylococcus albus 
found in about 90 percent of cancer cases; it 
sometimes does good by destroying the odor and 
rendering the patient more comfortable, but has 
no curative effect; bacillus pyocyaneus (puerperal 
sepsis); bacillus proteus vulgaris; bacillus lactis 
a6rogenes (otitis media, abdominal sinuses). See 
Serum Therapy. 
VAGINA, HEMORRHAGE.-Hemorrhages from 
the genital tract of the female are naturally divided 
into two classes: (1) Hemorrhages complicating 
pregnancy, labor, or the puerperium; (2) hemor- 
rhages occurring in the nonpregnant woman. 
1. Hemorrhages Complicating Pregnancy, Labor, 
or the Puerperium.- 
A. Hemorrhages of Pregnancy.- 
(1) Placenta praevia. 
(2) Premature separation of a normally situated 
placenta. 
(3) Rupture of varicose veins of the vagina or 
vulva. 
(4) Apoplexy of the decidua or placenta. 
B. Hemorrhages of Labor.- 
(1) Placenta prsevia. 
(2) Premature separation of a normally situated 
placenta. 
(3) Relaxation of the uterus. 
(4) Lacerations of the cervix, vagina, or vulva. 
(5) Rupture of the uterus. 
(6) Inversion of the uterus. 
(7) Hematoma of the vulva or vagina. 
C. Hemorrhages of the Puerperium.- 
(1) Retained secundines. 
(2) Displaced uterus. 
(3) Displaced thrombi. 
(4) Fibroid tumors. 
(5) Pelvic engorgement. 
(6) Hypertrophied decidua. 
(7) Carcinoma. 
2. Hemorrhages Occurring in the Nonpregnant 
Woman.- 
A. In Virgins before the Age of Thirty.- 
(1) Uterine congestion the result of cold or 
exposure. 
(2) Endometritis. 
(3) Polypi and fibroid tumors. 
(4) Retrodisplacement of the uterus. 
B. In Married Women before the Age of Thirty.- 
(1) Subinvolution. 
(2) Laceration of the cervix. 
(3) Endometritis. 
(4) Retrodisplacements of the uterus. 
(5) Polypi and fibroid tumors. 
C. In Virgins or Married Women after the Age 
of Thirty.-One should always suspect, in addi- 
tion to the above conditions: 
(1) Carcinoma of the cervix. 
(2) Carcinoma of the body of the uterus. 
(3) Sarcoma of the uterus. 
Hemorrhage from the female genitalia may also 
occur as the result of traumatism of any kind. 
Certain constitutional disturbances may cause it, 
such as purpura, scorbutus, and hemophilia. 
For the differential diagnosis of the various 
conditions causing hemorrhage from the va- 
ginal orifice, see under the respective headings, 
as Cervix Uteri, Labor, Placenta Previa, 
Postpartum Hemorrhage, Uterus (Fibroid 
Tumors), etc. 
VAGINAL DOUCHE.-The value of the hot 
douche was made known by Emmet. It should be 
given with a gravity syringe while the patient is 
in a recumbent position; the more prolonged, the 
larger the quantity, and the higher the temperature 
(115° to 120° F.), the more enduring will be the 
effect. The ordinary fountain syringe, a large 
vessel with a tube leading from its lower end, or an 
ordinary pitcher with a rubber tube carried to and 
held at its bottom by a weight, may be used. 
Instead of the ordinary rubber, wooden, or metal 
nozzle, a glass end-piece is preferable as it can be 
more readily cleansed. When preferred, the water 
may be medicated with astringents, such as alum, 
sulphate of zinc, acetate of lead, hydrastis, or 
hamamelis; or with antiseptics, as boric acid, 
carbolic.acid (2 to 5 percent), or permanganate of 
potassium (1 to 2 percent), and acid sublimate 
(1:5000 to 1:2000) are valuable. The antiseptic 
injections are of especial value in vaginal discharge, 
more particularly when of a specific character. 
The advent of menstruation is considered as con- 
traindicating irrigation, but it may be resumed 
before it ceases, particularly when the odor is 
offensive or the parts are irritated, using plain 
water at a temperature of 100° F. If the vaginal 
discharge is particularly offensive, as in malignant 
disease, a douche of thymol solution, 1 or 2 per- 
cent, is a most excellent deodorizer. Astringent 
douches are used in excessive vaginal sfecretion, 
but should not be used when the patient is wearing 
a pessary, as the salts are deposited upon the 
instrument, roughen its surface, and thus increase 
the irritation (Montgomery). 
VAGINAL FISTULA.-Fistulous openings may 
exist between the bladder, the urethra, the rectum, 
the ureter, and the vagina. 
Vesicovaginal fistula is much the most frequent. 
It is usually the result of labor. 
Symptoms.-Incontinence of urine is the first 
symptom. It usually appears about 6 or 8 days 
after labor, and is constant or not, depending upon 
the position of the opening. If the fistula is in the 
upper part of the vagina, incontinence may appear 
only when the bladder is distended or when the 
patient assumes the recumbent position. 
As the result of incontinence of urine, irritation, 
inflammation, and sloughing of the vaginal mucous 
membrane may occur. The vulva and inner part 
of the thighs become affected, and phosphatic 
deposits accumulate on the skin and mucous 
membrane. The kidneys may become • infected 
secondarily. 
The treatment consists in closure of the fistulous 
opening by a plastic operation. The edges of the 
opening must be denuded, and then closely approx- 
imated by interrupted sutures of silkworm-gut. 
If the condition has existed for some time and 
there are inflammation, excoriation, phosphatic 
deposits, and contraction, preparatory treatment 
VAGINAL FISTULA VAGINAL SPECULUM 
will be necessary. This consists of rest in bed, 
frequent vaginal douches of boric acid solution, 
applications of nitrate of silver solution to the 
excoriated areas, and stretching or incision of any 
contracting or adhesive bands that might interfere 
with the result of the operation. 
Rectovaginal fistula is also the result of labor. 
The important symptom is the passage of flatus 
cervix and the vaginal vaults come into view. 
This instrument can be used for inspecting the 
external os uteri, the cervix, and the vaginal 
vaults and walls; for applications to the uterus, 
VAGINAL SPECULUM 
Ferguson's Speculum. 
and feces into the vagina. Treatment should 
consist in closure of the fistulous opening by a 
plastic operation. 
VAGINAL SPECULUM.-A vaginal speculum is 
an instrument through which a visual examination 
is made of the cervix and the vaginal walls. The 
instruments most commonly used are some form 
of bivalve speculum and the Sims duckbill specu- 
lum. They have largely supplanted the tubular 
Edebohl's Speculum. 
cervix, and vagina; and for dilating and curetting 
the uterus. 
The Sims speculum may be introduced with the 
woman in the dorsosacral, the Sims, or the genu- 
Goodell's Speculum. 
pectoral position. In some cases the examination 
is facilitated by the use of an instrument for de- 
pressing the anterior vaginal wall. The Sims 
speculum gives the most perfect view of the cervix 
Sims' Speculum. 
(Ferguson) speculum by reason of their far wider 
range of application. They have the advantages 
of being self-retaining and of affording a much 
better exposure. 
Popular forms of bivalve specula are those of 
Collins and of Goodell. The bivalve speculum is 
introduced with the woman in the lithotomy 
position; the plane of the blades held obliquely, so 
Higbee's Bivalve Speculum. 
Self-retaining Sims' Speculum. 
that the edges may correspond to the vaginal 
sulci. The tip of the instrument should be passed 
directly toward the cervix. After it has been 
partially introduced, the blades should be turned 
so that they lie transversely, and as they are 
separated by the thumb-screw at the handle, the 
and vagina, and can be used advantageously in 
all operations upon the cervix and vagina. 
In the lithotomy position for retracting the 
perineum the Edebohls speculum to which a 
weight is attached is the most satisfactory. VAGINISMUS 
VANILLA 
VAGINISMUS.-A painful, spasmodic contrac- 
tion of the muscles surrounding the lower part of 
the vagina and the vulva. It is caused by attempts 
at coitus or by digital or specular examination. 
This condition is usually seen in newly married 
neurotic women. There is usually some exciting 
cause, such as a rigid hymen, a small vaginal 
orifice, a urethral caruncle, or an ulcer, a fissure, 
or some inflammatory condition around the vulva. 
Occasionally, it is a purely neurotic condition. It 
is sometimes seen in old women as a complication 
of kraurosis vulvse 
or bichlorid of mercury (1:4000). After 2 weeks 
the douches may be given 4 times a day of double 
the strength. In chronic cases after the subsid- 
ence of acute symptoms, astringent douches are 
employed, e. g., zinc sulphate (1/2 dram) and 
powdered alum (1 dram) added to a quart of water, 
or potassium permanganate (1:2000) or argyrol 
solution 25 to 50 percent. The vaginal walls are 
cleansed and painted with nitrate of silver solution 
(1 dram to 1 ounce) and boroglycerid tampons are 
inserted. Tampons of ichthyol in lanolin (1:4) 
are valuable. Treatment should be continued 
until all evidence of the disease has dis- 
appeared. 
VAGUS NERVE.-See Pneumogas tric 
Nerve. 
VALERIAN.-The dried rhizome and 
roots of Valeriana officinalis. It contains 
a volatile oil, from which are developed 
by oxidation valerene, C10H16, a terpene; 
valerol or Baldrian Camphor, C]2H20O; and 
valeric acid, C5H10O2, which occurs also in 
many other plants and in cod-liver oil. The 
valeric acid of pharmacy is obtained as a prod- 
uct of the oxidation of amylic alcohol, and 
from it are formed the various valerates. It 
is nottherapeutically identical with the natural acid. 
Dose of the powdered root, 10 to 45 grains. It is 
antispasmodic and is gently stimulant to the 
nervous system and the organs of circulation. In 
full doses it increases heart action, producing 
exhilaration; in toxic doses, diarrhea, vomiting, 
reduced sensibility, and mental disturbance. It 
is excellent in hysteria, in convulsions due to 
worms, in the coma of typhus fever, and in whoop- 
ing-cough. 
Preparations.-V., Flext. Dose, 10 to 45 
minims. V., Tinct., 20 percent. Dose, 1/2 to 2 
drams. V., Tinct., Ammoniat., valerian 20, 
aromatic spirit of ammonia enough to make 100 
parts. Dose, 5 to 45 minims. V., 01., the volatile 
oil (unofficial). Dose, 1 to 5 minims. The oil is 
the best preparation to use, as the tinctures are 
extremely nauseous, and the fluidextract is too 
bulky. 
VALGUS.-See Talipes Valgus. 
VALIDOL.-The menthol-ester of valeric acid 
containing 30 percent of free menthol. A car- 
minative and antihysteric, combining the activites 
of its components. It is said to produce no gastric 
irritation and is recommended in hysteria and 
sea-sickness and the vomiting of pregnancy 
Dose, 10 to 15 drops on sugar. 
VALVULAR DISEASE.-See Heart-disease 
(Organic). 
VALYL.-Valeryldiethylamid. A compound of 
valeric acid and diethylamin. It is a sedative, 
nervine, antispasmodic, similar to valerian. 
Dose, 2 or 3 gelatin capsules, each containing 2 
grains. 
VANILLA.-The fruit of V. planifolia, an orchid 
found in tropical America, and of other species of 
the genus. Its odor is due to a methyl-ether, 
vanillin. It is an aromatic stimulant, sometimes 
employed in hysteria and low fevers, but it is used 
chiefly as a flavor. V., Tinct., 10 percent. Dose, 
The treatment of this condition consists, first of 
all, in ascertaining its exciting cause. This, if 
possible, must be removed. A rigid hymen may 
be incised and a small vaginal orifice may be di- 
lated. A urethral caruncle should be excised, and 
any inflammatory condition around the vulva 
should be appropriately treated. 
A vaginal suppository containing 1/2 grain of 
cocain, introduced 15 minutes before intercourse, 
will sometimes prove effective. Gradual or 
forcible dilatation of the vagina will occasionally 
give relief. 
In the gravest cases it will be necessary to make 
incisions in the direction of the posterior vaginal 
sulci. These incisions should be deep enough to 
divide the underlying muscles and fasciae; and to 
prevent retraction a glass vaginal plug should be 
worn for a few days. When the condition is a 
purely neurotic one, constitutional remedies 
should be employed. 
VAGINITIS.-Inflammation of the vagina, or 
vaginitis, is usually secondary to some other con- 
dition, such as vulvitis, endometritis, or a fistula 
of the bladder or rectum. Occurring as a primary 
condition, it is usually due to gonorrhea. Four 
varieties of vaginitis have been described-simple, 
granular, senile, and emphysematous. 
The symptoms of vaginitis are pain and a sense 
of fulness in the pelvis-which are increased by 
walking or movement of any kind-and a purulent 
discharge. As the disease becomes chronic it 
tends to localize itself particularly to areas about 
the ostium and vaults. 
The treatment in the acute stage consists of rest 
in bed and mild purgation, and in the employment 
of vaginal douches. The douches should consist 
of a gallon of hot boric acid solution (1 dram to 1 
pint) every 2 or 3 hours. After the acute symp- 
toms have subsided, douches should be given 
every 3 hours of potassium permanganate (1:4000), 
Trivalve Speculum. VAPOR BATH 
VARICELLA 
a few drops, according to the flavor desired. 
Vanillin, C8H8O3, crystallizes in stellate groups of 
colorless needles, is soluble in hot water, alcohol, 
and ether. It has a warm, aromatic taste. 
Commercial vanillin is in part prepared from the 
inner bark of white pine and from eugenol. Dose, 
1/4 to 1 grain. 
VAPOR BATH.-The application for thera- 
peutic purposes of steam (medicated or otherwise), 
or of some other vapor, to the surface of the body, 
in a suitable apartment or apparatus. See Bath. 
VARICELLA (Chicken-pox).-Varicella is an 
acute contagious disease, characterized by a 
cutaneous eruption of papules, vesicles, and, 
occasionally, pustules; by mild constitutional 
symptoms, and by the absence, as a rule, of com- 
plications and sequels. 
Etiology.-The specific poison has not been 
isolated, but it has been proved that the con- 
tagium of the disease is found in the vesicles. 
Varicella is directly very contagious, and it may, 
in rare cases, be carried by a third person. Chil- 
dren of any age may be affected by it, but one 
attack gives immunity. The period of incubation 
is from 14 to 16 days. 
Symptoms.-In many cases the eruption is the 
first symptom, though there may be noticed slight 
fever and general indisposition for 24 hours 
preceding it. The eruption consists of first a 
macule and then a papule, but these so rapidly 
become vesicular that the vesicle is usually 
the first lesion noticed. The vesicle is tense 
transparent or slightly yellow, and is about 
the size of a split pea. The eruption appears 
first upon the upper part of the body and upon the 
neck, scalp, and face. Usually, the face escapes 
with a few lesions, but the hairy scalp contains 
quite a number. 
The vesicles frequently form on the mucous 
surface of the lips, mouth, throat, conjunctiva, and 
progenital region; and when occurring on these 
parts, bear a characteristic appearance, owing 
to the fact that they quickly lose their delicate 
covering, and then resemble aphthous ulcers 
with a well-marked red zone around them. 
The eruption appears in successive crops, and 
different stages are found at the same time and in 
close proximity. The eruption begins to disappear 
in a few days after its appearance. Some of the 
vesicles become flaccid or slightly umbilicated 
from the absorption of their contents, and others 
rupture, either spontaneously or from scratching. 
They finally dry up and the crusts drop off, leav- 
ing small circular marks, which soon disappear. 
In cases in which the vesicles have become in- 
fected or in which they are very deep, permanent 
scars or pits remain. 
Pustules may develop in consequence of irri- 
tation or infection, or in feeble or poorly nourished 
children. In rare cases there may be necrotic 
inflammation around the site of the pock, a con- 
dition to which is given the name varicella gan- 
gramosa. 
In mild cases about a dozen vesicles may appear 
upon the body; but when severe, the skin may be 
covered in certain regions. In mild, uncomplicated 
cases the temperature reaches 101° to 102° F., 
and lasts only two or three days, being highest 
when the eruption is appearing and falling grad- 
ually as it fades. There are no characteristic con- 
stitutional symptoms, but there is present more 
or less severe indisposition, as found associated 
with any febrile disease, the child frequently 
not being ill enough to remain in bed. 
Complications.-Erysipelas may occur from 
infection by the vesicle, and acts as a serious 
complication. Mild adenitis is occasionally seen. 
Nephritis may occur, but it is rare as a result of 
varicella. The other infectious diseases of child- 
hood (measles, scarlet fever, etc.) quite frequently 
occur just before, at the same time, or closely 
following chicken-pox, and when present at the 
same time, render the diagnosis in some cases 
very difficult. 
Diagnosis.-As a rule, the diagnosis of varicella 
offers no special difficulty. The fact that the 
eruption appears in crops, so that papules, vesicles, 
and crusts are seen in close proximity; that the 
vesicles are unilocular; and that they are never 
confluent, serve to distinguish it from other 
eruptive affections. In certain cases, however, 
it is difficult, if not impossible, to distinguish 
this disease from a mild form of variola. The 
following table will aid in the diagnosis: 
Varicella. 
Variola. 
Incubation,.... 
Two weeks 
One to two weeks. 
Prodromes 
None, or slight 
Three or four days in 
duration; active; se- 
vere.' 
Efflorescence, .. 
On the skin; rapidly 
becomes vesicular; 
not umbilicated; 
unilocular; irreg- 
ular; numerous; 
universally distrib- 
uted in successive 
crops; vesicles dif- 
fer greatly in size; 
on pricking, col- 
lapse entirely. 
Under the skin; a 
slow progressive de- 
velopment from a 
macule to a papule, 
to an umbilicated 
vesicle, to a pustule; 
multilocular; regu- 
lar; not numerous; 
defined in its locali- 
zation; lesions, as a 
rule, of uniform 
size; on pricking, 
collapse partially. 
Desquamation, 
Slight crust forma- 
tion. 
Pronounced crust 
formation. 
Duration, 
Short; 1 week to 10 
days. 
Long; 3 to 4 weeks. 
Type 
Mild 
Severe. 
Temperature, .. 
Irregular; not high. . 
Rises suddenly; re- 
mains high until 
papules are devel- 
oped, when it falls 
considerably; rises 
again during devel- 
opment of the pus- 
1 tules. 
- 
Prognosis.-The prognosis is invariably good, 
except when the disease occurs in weak and 
debilitated children whose hygienic surroundings 
and care are faulty. 
Treatment.-Isolation should be enforced in 
schools and institutions containing many young 
children. In homes, unless the younger children 
are delicate, quarantine is unnecessary. In 
most cases the constitutional symptoms are so VARICOCELE 
VARICOCELE 
mild as to require no treatment. It is best at 
the outset to place the child in bed for a few days 
and to sponge daily with warm, carbolized water, 
applying carbolized vaselin to the vesicles to 
allay the itching. Later, when the crusts have 
formed, the following ointment is useful: 
Apply locally: 
1$. Carbolic acid, rq xv 
Boric acid, 3 jss 
Glycerin, 5 iij 
Rose-water, 3 j 
Water, enough to make 5 iv. 
Apply to affected parts once daily. 
Or: 
3. Carbolic acid, rq v 
Ichthyol, 5 jss 
Vaselin, enough to make 3 j. 
Apply on soft cloth once daily. 
1$. Ichthyol, gr. x 
Zinc ointment, 3 j. 
A light diet, of milk, soups, and eggs. If the 
tongue is coated, calomel (1/8 grain) may be 
given every 1 1/2 hours until 4 or 5 doses have 
been taken. 
Care should be taken to keep the skin clean and 
to prevent scratching. In all cases the urine 
should invariably be examined several times dur- 
ing and following the attack. Quarantine should 
be instituted for 2 weeks. 
VARICOCELE.-Dilated and varicose condi- 
tion of the spermatic veins. 
The causes of varicocele are not definitely 
known. It has been attributed to an abnormally 
lax state of the parts, induced by debility and gen- 
eral want of tone; to congestion from too early or 
continual excitement of the sexual organs; to 
occupations involving prolonged standing; and to 
certain anatomic peculiarities (all of which, how- 
ever, are present in every healthy male) such as 
the great length of the spermatic veins, the 
dependent position of the testicle, the plexiform 
arrangement of the veins in the scrotum, etc. 
But it often occurs in men in good health, and in 
whom the parts are not lax. The reasons given 
for its much greater frequency on the left than on 
the right side are: (1) that the left vein is longer 
than the right; (2) that an obstacle is offered to 
the outlet of the left vein by its opening at right 
angles into the renal vein; (3) that the blood-pres- 
sure is less in the vena cava than in the renal vein; 
(4) that the left vein is crossed by the sigmoid 
flexure, and is hence liable to be pressed upon by 
fecal accumulations. Spencer believes that the 
presence of the large veins is due to a congenital 
variation from the normal process of development, 
whereby many of the veins of the wolffian body 
(from which the spermatic veins are formed) 
remain unobliterated, and capable of being 
dilated by anything obstructing the return of 
venous blood from the testicle. More of these 
veins, he says, are normally obliterated on the 
right than on the left side. 
Symptoms and Diagnosis.-There may be 
merely a sense of weight and fulness in the scro- 
turn, or dragging or even severe pain, worse 
after the day's work, but relieved by recumbency. 
The symptoms, however, are often more mental 
than physical, the patient fearing impotence or 
sterility, and sometimes becoming hypochondria- 
cal in consequence. The varicose veins, which 
may sometimes be seen through the skin of the 
scrotum, form a soft, irregular, opaque, knotted, 
pyriform mass, in which there is a distinct expan- 
sile thrill or impulse on cough. The swelling is 
confined to the scrotum, and although it may be 
reduced on the patient's lying down, it does not 
go back with a gurgle or slip like a hernia, and 
gradually returns when the patient rises, notwith- 
standing that the finger is placed over the external 
abdominal ring. The testicle, though perhaps, 
as a rule, a little smaller than natural, is seldom 
much atrophied. 
Treatment.-In the vast majority radical meas- 
ures are entirely out of place; varicocele seldom 
causes inconvenience after early manhood is past. 
A suspensory bandage should be worn, one that 
is not too warm or too complicated; the parts 
should be bathed with cold water night and morn- 
ing; the bowels should be opened regularly; a fair 
amount of exercise should be taken; and stimu- 
lants, sexual excitement, etc., should be avoided. 
It is only when the health is impaired that the 
weight of the part is noticed. Occasionally, how- 
ever, this is not sufficient; the patient may wish to 
enter the Government service; both sides may be 
involved; the varicocele may be serious from its 
size, the rapidity of its enlargement, or the danger 
of rupture or phlebitis (which is not uncommon in 
connection with gout); the testis may be irritable 
and tender, or the patient very much troubled 
about its condition. In those cases in which 
there is any reason to fear the development of 
hypochondriasis, every endeavor must be made to 
divert the patient's attention from the disorder; 
but too often the attempt ends in complete failure, 
and, though the prospect is not an inviting one, 
there is no alternative. Pearce Gould considers 
operation advisable in all cases in which varicocele 
develops before puberty. 
Operation.-The older method, in which a liga- 
ture was passed around the veins subcutaneously 
in one or more places, is practically abandoned: 
the result is uncertain, and there is great risk of 
transfixing a vessel. Even the addition of sub- 
cutaneous section does not increase the security. 
The method ordinarily adopted is to expose the 
veins freely, so that the structures to be dealt 
with can be seen; isolate the vas deferens with the 
spermatic artery, ligate the vessels above and 
below, and excise the intermediate portion. 
Pearce Gould, however, considers subcutaneous 
section with the cautery preferable. 
The patient is placed under an anesthetic, the 
parts are shaved and cleansed, and an incision of 
sufficient length is made along the cord, exposing 
the fascia that surrounds the veins. . The vas is 
then carefully separated at the back, taking care 
not to isolate it, but to leave the fascia around it 
untouched; a catgut ligature is passed around the 
rest of the fascia and the veins above, a second VARICOSE VEINS 
VARICOSE VEINS 
ligature below, and the intervening portion is 
excised. Practically, if the separation is com- 
menced above, all the veins are included but one 
or two little ones with the vas. The length to be 
excised depends, as Bennett has shown, upon the 
height to which it is wished to raise the testicle, 
and after excision the two cut ends should be 
sutured together, so that the shortening of the 
fascia may help to support the gland. No drain- 
age-tube is needed, unless there has been much 
handling. The swelling afterward is considerable, 
and the testis may be a little tender, but orchitis 
does not follow. An ice-bag may be applied for 
48 hours as a precaution. The patient should 
remain in bed for 10 days or 2 weeks, by which 
time the induration will have disappeared, and 
should wear a suspensory bandage for some 
months (Moullin). 
VARICOSE VEINS.-A vein is said to be vari- 
cose when it is permanently and unequally dilated, 
and when its coats have undergone certain degen- 
erative changes. A varicose condition is most 
common in the veins of the lower extremities and 
in the veins of the rectum and testicle. See 
Hemorrhoids, Varicocele. 
The causes may be considered under the heads 
of increased intravenous pressure and changes in 
the vein-walls. 
Increased intravenous pressure may be due to: 
(1) Organic affections of the heart whereby the 
return of venous blood is impeded. (2) Obsrtuc- 
tion to the circulation in the portal system, a 
cause chiefly affecting the hemorrhoidal veins. 
See Hemorrhoids. (3) Pressure upon the veins, 
such as may be exerted (a) by the gravid uterus 
or by a tumor of the uterus or of the ovaries on 
the iliac veins; (b) by an aneurysm of the abdom- 
inal aorta on the inferior vena cava; (c) by fecal 
accumulation on the hemorrhoidal veins; (d) by a 
tumor in the groin on the femoral vein; (e) by an 
ill-fitting truss on the spermatic veins (see Vari- 
cocele) ; or (/) by a tight garter on the saphenous 
veins. (4) Prolonged standing, which has a ten- 
dency to cause the accumulation of blood in the 
veins of the lower extremity. (5) Severe muscu- 
lar exertion, whereby an increased amount of 
blood is driven by the contraction of the muscles 
from the deep into the superficial veins. 
Some authors consider this last the chief, if not 
the only, cause of varicose veins of the lower 
extremities. They maintain that the pressure of 
the blood first produces a dilatation of the super- 
ficial veins where the intermuscular veins empty 
into them; that this dilatation, being frequently 
repeated, becomes permanent; that the valves, in 
consequence, are unable to close and protect the 
veins, and, being thrown out of use, gradually 
undergo atrophy, while the weight of the column 
of blood, from the inefficiency of the valves, 
becomes further increased and the veins are still 
further dilated. 
Changes in the Vein-walls.-These consist prin- 
cipally of a hereditary weakness, a want of 
muscular tone, and an inflammatory softening of 
the walls. Varicose veins are more common in 
men than in women, owing to their more frequent 
exposure to the exciting causes. Women, how- 
ever, are peculiarly liable to them during preg- 
nancy. 
The symptoms usually complained of are fatigue 
and a sense of fulness of the limb after exercise or 
prolonged standing, and perhaps cramp, coldness 
of the feet, swelling and edema of the ankle, and 
numbness of the leg. Sometimes there is deep- 
seated pain. The tortuous vein or veins meander- 
ing up the leg is a characteristic sign, and cannot 
be mistaken. When the smaller radicals are af- 
fected, bluish clusters of minute veins are visible 
here and there, especially about the ankle and 
knee. 
Treatment is palliative and radical. 
Palliative.-All obstructions must be removed, 
as far as possible. Tight garters are exceedingly 
injurious. In pregnancy the patient must rest as 
much as possible, or as much as is consistent with 
health, and should wear a bandage or an elastic 
stocking both during and for some time afterward. 
The bowels must be kept well open, and prolonged 
standing and excessive walking should be avoided, 
although a reasonable amount of exercise, avoiding 
fatigue, is decidedly beneficial. 
If the varix has made its appearance suddenly 
after exertion, the walls of the vein must be care- 
fully protected from strain for some considerable 
time. The limb should be kept at rest in the 
horizontal position, for 2 or 3 weeks, according to 
the size of the vein, and then carefully supported. 
In the majority of cases all that can be done is to 
caution the patient against the evil effects of 
standing, etc.; to maintain the general health by 
means of tonics, combined with good food, fresh 
air, and a fair amount of exercise; and to supply 
some kind of support. Silk anklets, elastic 
stockings, and the appliances generally in use 
serve the purpose for which they are intended very 
ill; they produce the maximum of constriction 
when first applied, and then each w eek relax more 
and more until replaced; they are usually much too 
tight, and generally cause considerable wasting of 
the muscles. If worn once, the limb becomes so 
used to their pressure that the patient can hardly 
be induced to leave them off. Bandages of thin 
flannel, domet, or perforated rubber are much 
better, as they can be put on with just sufficient 
pressure and no more, instead of an iron rule being 
followed in all cases alike. Upward friction and 
massage should be practised every night when the 
appliance is removed. If bleeding threatens, the 
part should be well bandaged and kept at rest; if 
it breaks out (the usual situation is the lower third 
of the leg), the limb must be raised at once. The 
hemorrhage is exceedingly profuse, but it comes 
from the proximal or cardiac end, and raising the 
limb stops it instantly. If inflammation sets in 
and the veins become hard and painful, showing 
that they are filled with clots, the patient should 
be confined to bed and the limb should be placed 
in a slanting position on a leg-rest and covered 
with lead lotion. 
Radical.-In a certain number of cases the 
radical cure may be tried. As a rule, it is only 
advisable when the superficial veins are concerned, VARICOSE VEINS 
VASOCONSTRICTORS 
and when the part involved is limited in extent. 
Sometimes, however, it is beneficial in cases, of 
varicose ulcer, in which the persistence of the sore 
appears to be dependent upon the vein. The 
choice lies between acupressure (with or without 
subcutaneous division), ligation, and excision. 
Acupressure.-This is performed by passing a 
flat needle beneath the vein, while it is pinched up 
with the finger and thumb, and then twisting a 
figure-of-eight suture over the ends, protecting the 
skin beneath by means of a piece of bougie or quill. 
The needles should be about 3/4 of an inch apart, 
and the vein may be divided subcutaneously 
between them with a tenotomy knife. They 
the following manner: the vein exposed and iso- 
lated near the saphenous opening and divided 
between ligatures and the peripheral portion 
grasped with a hemostat. The vein is passed 
through the loop of Mayo's dissector. Guided by 
the vein the dissector is pushed under the skin 
down to a point near the knee. The skin is incised 
over the end of the dissector. The vein clamped, 
pulled out through the wound, ligated and the 
loose portion excised. If the dissector is ob- 
structed in its work by adhesions around the 
vein, the closed forceps is passed alongside it and 
when the adhesions are reached the blades of the 
forceps are slightly opened. In the same manner 
Mayo's Operation. 
should not be left in for more than a week, and if 
any inflammation occurs, the time should be 
shortened. Failure is not infrequent, and there is 
always the risk of transfixing the vein. 
Ligation.-A small incision is made over the 
vessel and an aneurysm needle is passed around it 
and threaded with catgut. The ligature left when 
the needle is withdrawn is tied and the ends cut 
short. This method may be combined with the 
former, ligatures being placed in the intervals 
between the pins. Subcutaneous ligation may be 
tried in suitable cases. 
Excision.-This is by far the most effective 
method. The skin over the vein is reflected, the 
incision being as far as possible longitudinal; the 
vessel is carefully isolated from the surrounding 
tissue, a double ligature (catgut) is placed around 
it at each end and around each branch, and the 
whole intervening portion is excised. 
C. H. Mayo excises the long saphenous vein in 
as many other veins are removed as may be nec- 
essary. The dissection is made from above down- 
ward to avoid the danger of detaching thrombi and 
throwing them into the circulation. 
Schede's operation consists in making an 
incision completely around the leg down to the 
deep fascia and doubly ligating all the divided 
veins. 
VARIOLA.-See Small-pox. 
VARIOLOID.-See Small-pox. 
VASELIN.-See Petrolatum. 
VASOCONSTRICTORS.-Drugs that increase 
the contractile power of the vessels, lessening the 
circulation therein and raising the blood-pressure; 
hence they are used to check hemorrhage and cut 
short inflammations. The principal agents are: 
Adrenal extract, adrenalin, antipyrin, cotarnin, 
hydrastinin, strychnin, hamamelis, atropin (small 
doses), opium (small doses), cocain, ergot, digitalis, 
squill, strophanthus, iron, camphor, sulphuric VASODILATORS 
VEINS, INFLAMMATION 
acid, barium salts, lead salts, silver salts, zinc salts, 
cold (locally). 
These agents act upon the local vasomotor 
mechanism in the walls of the vessels, hamamelis 
affecting the venous system especially. Cold is 
one of the most powerful agents of this class, and 
is also a cardiac sedative. Adrenal extract pro- 
duces an enormous rise of the blood-pressure, due 
to its extraordinary contractile power over the 
muscular fibers in the walls of the arterioles. 
Adrenalin is said to be 625 times more powerful in 
this respect than the extract. Digitalis, squill, 
and strophanthus, in small doses contract the 
vessels, but in large doses dilate them. 
VASODILATORS.-Drugs that produce dilata- 
tion of the peripheral vessels, and increase the 
rapidity of the circulation, thus equalizing the 
blood-pressure and relieving internal congestions. 
The most useful are alcohol and ether, as they 
stimulate the action of the heart simultaneously 
with the vascular relaxation. The chief are: 
Alcohol, ether, nitrous ether, nitroglycerin, amyl 
nitrite, potassium nitrite, sodium nitrite, erythrol 
tetranitrate, belladonna (at last), stramonium (a, 
last), hyoscyamus (at last), opium (full doses)t 
ipecacuanha, Dover's powder, thyroid extract, 
chloral, chloroform, ammonium acetate, tartar 
emetic, hydrocyanic acid, aconite (?), heat (at 
first). 
The nitrites are our most certain, in fact almost 
our only certain remedies to dilate the blood- 
vessels (Wood). The dilating action of amyl 
nitrite and other nitrites is due either to weakening 
of the muscular walls of the arterioles or to par- 
alysis of the vasomotor terminals therein. Alco- 
hol, ether and opium probably depress the vaso- 
motor center. Aconite does not affect the vaso- 
motor center of the vasomotor nerves, hence the 
lessened arterial tension induced by it is due to its 
depressant action on the heart alone (Ringer). 
Atropin and its congeners act on the vessels 
differently in different doses, and at different 
stages in its action. 
Vasodilators are often called vascular stimulants 
or stimulants of the circulation; but there is this 
difficulty of speaking of stimulants or sedatives of 
the circulation, that if both the heart and the 
vessels are stimulated at the same time, the action 
of the one tends to counteract that of the other. 
On the other hand, a drug which weakens the 
heart may increase the circulation by dilating the 
vessels, thus acting as a vascular stimulant 
(Brunton). 
VEINS, INFLAMMATION (Phlebitis).-Phlebitis, 
or inflammation of veins, may be divided into the 
simple and the septic or spreading. 
Simple phlebitis, formerly known as adhesive 
phlebitis, is a simple local inflammation of the vein- 
wall, and may terminate in resolution, in oblitera- 
tion of the vein, or, more rarely in the formation 
of a localized abscess. 
Causes.-(1) Injury of the vein-walls; (2) 
simple inflammation of the surrounding tissues; 
(3) the formation of a noninfective thrombus in a 
vein; (4) gout or the gouty diathesis; (5) certain 
conditions of the system the exact nature of which 
is not known, the phlebitis being then spoken of 
as idiopathic. 
Symptoms.-When the vein is superficial, it 
can be felt as a hard, knotted cord, standing out 
under the skin and surrounded by inflamed cellular 
tissue. It is exceedingly tender to the touch, 
but, unless the periphlebitis is very acute, and the 
vein is quite under the surface (as in the case of a 
varicose internal saphena), the skin is seldom 
much reddened. There is often a very consider- 
able degree of pain and stiffness, especially on 
movement, or when the limb is allowed to hang 
down; and sometimes there is profound constitu- 
tional disturbance. In the case of the deeper 
veins the diagnosis chiefly rests upon the deep- 
seated hardness and tenderness, the peculiarly 
clumsy appearance of the part, the sense of weight 
and pain when the limb is allowed to hang down, 
the relief as soon as it is raised, and the evident 
distention of the more superficial vessels. Gener- 
ally, a certain amount of superficial edema can 
be detected on the distal side of the obstruction: 
around the malleoli, for example, in cases of 
phlebitis of the deep veins of the leg. 
Gouty, rheumatic, and syphilitic phlebitis can 
only be distinguished by the other symptoms that 
accompany these disorders; they have no certain 
distinctive character of their own, although the 
gouty variety is occasionally metastatic. They 
all have a decided tendency to symmetry, they 
affect the superficial veins rather than the deep 
ones and the lower limbs much more frequently 
than the upper. Recurrence is exceedingly com- 
mon in the gouty variety, and may continue in 
the syphilitic form all through the secondary period, 
but it is seldom that permanent obliteration is 
caused by either gout or syphilis. 
Treatment.-Rest is absolutely essential until 
at least all trace of inflammation and tenderness 
has disappeared. Serious extension of the throm- 
bus and detachment of outlying fragments, 
causing embolism, are rare accidents, considering 
the very large number of cases of phlebitis of 
varicose veins of the leg; but they do happen occa- 
sionally, and every precaution must be taken to 
avoid them. 
Elevation is no less essential, for the sake of the 
return circulation and to relieve tension. Cold 
lead lotion, as a rule, causes the inflammation to 
subside within a few days; but in cases of gout, 
and when the arteries are atheromatous, bella- 
donna (equal parts of the extract and glycerin) 
and warmth should be used instead. The bowels 
should be kept well open; the diet should be light, 
without stimulants, and if there is any evidence of 
gout, rheumatism, or syphilis, appropriate reme- 
dies should be employed. Afterward, when all 
the inflammation has subsided, the patient may 
be allowed to go about with a support; if the leg 
is much wasted, or has a tendency to remain cold 
or edematous, massage may be used to improve 
the circulation. 
Suppurative Phlebitis.-This, too, may originate 
either as a periphlebitis or in the interior. Ex- 
amples of the former are often seen in diffuse in- 
flammation of the cellular tissue; the pyogenic or- VEINS, INJURIES 
VENESECTION 
ganisms rapidly destroy the coats of the veins, 
spreading along the loose cellular tissue around 
them, and causing them to slough or to melt away 
into the purulent fluid that fills up every interstice. 
As the endothelium is approached coagulation 
takes place, and although the thrombus shares the 
fate of all the rest of the structures, fortunately, in 
the vast majority of cases, the coagulation ex- 
tends sufficiently far and with enough rapidity 
to act as a barrier and to prevent the poison from 
spreading far and wide in the circulation. If it 
fails, or if it is broken down, general pyemia is 
almost certain. This is of common occurrence in 
acute suppurative osteomyelitis and in otitis media, 
infective inflammation, with thrombosis, spreading 
along the coats of the veins into larger and larger 
trunks, until at length the puriform clot that fills 
the vessel gives way and is scattered all over the 
body, causing metastatic abscesses wherever it 
enters. 
Acute spreading phlebitis of the same character, 
and ending in embolic pyemia in the same way, 
may begin in the interior of a vein as well as around 
it. This, of course, unless pyemia has already 
developed, can only take place after the cavity 
of the vein has been opened. Usually, under 
these circumstances, the vessel either collapses 
at once or a coagulum forms and extends up to 
the next set of valves or to the next larger branch. 
If, however, septic decomposition sets in before 
organization has taken place, and lends its aid 
to ^the micrococci of suppuration, the clot melts 
away at once into an infective puriform fluid, 
and there is every chance of a wide-spread dis- 
tribution of infective emboli all over the body, 
even before the rest of the tissues succumb or 
before the diffuse cellulitis assumes alarming 
proportions (Moullin). 
VEINS, INJURIES.-Rupture or subcutaneous 
laceration of a vein occasionally occurs from 
causes similar to those producing rupture of an 
artery-an accident, moreover, with which it is 
frequently associated. When the vein is of large 
size, much blood may be extravasated into the 
tissues, and may produce gangrene by pressure 
on the vessels carrying on the collateral circula- 
tion, though such a result is much less com- 
mon than after rupture of an artery. The blood, 
except when the extravasation is large, is usually 
absorbed, but it may break down and suppuration 
ensue. 
Wounds.-Punctured and incised wounds, when 
small and parallel to the long axis of even large 
veins, readily heal by adhesive inflammation 
without obliteration of the lumen of the vessel. 
At times, however, a clot may form in the wound, 
and successive layers may be deposited upon it 
until untimately the vein is occluded. When a 
vein is completely cut across, as in amputation, 
it usually collapses as far as the next pair of valves, 
a clot forms as high as the first collateral branch, 
and the vein becomes permanently occluded. In 
consequence, however, of the vein-wall contain- 
ing less elastic and muscular tissue than an artery, 
bleeding sometimes continues unless stopped 
artificially. 
Treatment.-When the wound is a mere punc- 
ture in the continuity of the vein, unless it is 
found that pressure will control the hemorrhage, 
the coats should be nipped up by forceps and a 
lateral ligature applied. If a vein continues to 
bleed during an amputation, it should be tied like 
an artery. A large wound, or one made in the 
longitudinal axis of a large vein, necessitates 
ligation of the vein in two places, and the division 
of the vessel between the two ligatures. See 
Arteries (Injuries). 
The dangers of wounds of veins are: (1) Hemor- 
rhage; (2) inflammation of a septic character, 
and the attendant risks of blood-poisoning from 
the detachment of the infected clots; (3) entrance 
of air. 
Entrance of air inter veins is fortunately a rare 
accident. It sometimes happens in operations 
about the root of the neck, where the disposition 
of the cervical fascia prevents the veins collapsing 
and thus allows air to be sucked in during in- 
spiration. Air is known to have entered a vein 
by the hissing sound during inspiration, the escape 
of frothy blood from the vein on expiration, the 
urgent dyspnea, and the state of collapse into 
which the patient immediately falls. On listening 
over the heart a peculiar churning sound can be 
heard. Death in fatal cases usually occurs in a 
few minutes, and is due to the admixture of blood 
and air preventing the circulation through the 
capillaries of the lungs, and so causing distention 
and paralysis of the right side of the heart. 
Treatment.-The finger should at once be placed 
over the hole in the vein to prevent more air 
entering, and a clamp or ligature should be applied 
as soon as practicable. Pouring water into the 
wound has been suggested both as a means of pre- 
venting the further entrance of air during inspira- 
tion, and of allowing that which is already in to 
bubble out during expiration. The patient should 
be placed with his head low to insure a sufficient 
supply of blood to the brain, and for the same pur- 
pose the arteries of the extremities should be com- 
pressed, while injections of ether or of brandy 
should be given subcutaneously to stimulate the 
heart Artificial respiration should not be per- 
formed until the vein is secured, lest more air be 
sucked in. To guard against the accident the 
veins should be clamped before division, and in 
removing a tumor traction should not be made 
at the moment the vein is severed (Walsham). 
VEINS, VARICOSE.-See Varicose Veins. 
VENEREAL DISEASES.-See Syphilis, Chan- 
croid, Gonorrhea. 
VENESECTION (Phlebotomy).-Venesection, 
though not so often employed in modern surgery 
as in ancient days, has been considerably discussed 
lately, and is again coming into use. It is at times 
most beneficial in very acute inflammations in 
young and plethoric subjects. 
The blood may be taken from one of the veins 
of the arm-usually from the median basilic vein, 
as that is the larger vessel-or from the external 
jugular vein. In bleeding from a vein of the arm, 
a bandage or tape is carried twice around the arm 
a little above the elbow, to obstruct the vein, and VENESECTION 
VENTILATION 
is tied in a bow. Grasping the arm with the left 
hand, with the thumb steadying the vein, the 
surgeon makes an incision into the vessel, holding 
the lancet with the blade between his forefinger 
and thumb, about 1/2 of an inch from the point, 
to prevent it penetrating too deeply. The blood 
is directed into a graduated bleeding-bowl, the 
flow, if necessary, being increased by having the 
patient firmly grasp a stick. When sufficient 
blood has been taken (usually about 10 ounces) 
the constricting tape is untied, a pad is placed over 
the incision, and the ends of the tape are carried 
across the pad to below the joint, then around the 
arm, and again over the pad, where theyare tied. 
Uses.-Sanquirico has established that within 
certain limits venesection never produces func- 
tional alterations or disturbances in the nutrition 
in animals. Maragliano has reported a number of 
tests and experiments demonstrating that impov- 
erishing the blood has no injurious effect upon the 
evolution of infective diseases, but is even directly 
beneficial when the lungs are not working prop- 
erly and are unable to eliminate the excess of car- 
bonic acid formed in a blood particularly rich in 
red corpuscles. Traube expressed this fact when 
he stated that persons whose blood contains 
fewer red corpuscles than the average are less 
affected by pulmonary disturbances than others, 
and that even a small amount of lung surface is 
sufficient to eliminate their carbonic acid. This 
fact explains the manifest improvement after 
venesection in pneumonia, which he has observed 
again and again in his own practice; the dyspnea 
and cyanosis decrease, while the elimination of car- 
bonic acid increases. On the other hand, in cases 
of circumscribed pulmonary lesions the elimination 
of carbonic acid decreases after venesection, 
showing that the elimination had been practically 
normal. Recent research (Robin) has proved that 
venesection promotes oxidation processes in pneu- 
monia, and everything tends to the assumption 
that when the corpuscles are inert, they are use- 
less. Maragliano agrees with Zakharine that 
venesection is especially beneficial in active con- 
gestions with hemorrhage, especially hemorrhage 
of the respiratory apparatus and brain. The 
amount necessary to obtain the mechanic effect 
required in these cases is from 200 to 400 c.c. 
Zakharine even ascribes a revulsive action to phle- 
botomy, claiming that the congestion may be 
drawn to a remote vascular region; and Calabrese 
adds two corroboratory observations of severe, re- 
bellious hemoptysis in tuberculosis, arrested by a 
few leeches applied to the base of the thorax. 
Maragliano has dwelt upon the advantages of 
venesection in eliminating the toxins circulating 
in the blood, especially in renal or pulmonary 
insufficiency, or when there is some obstacle to the 
passage of bile into the intestines, and also in the 
autointoxications resulting, usually, from the 
suppression or functional alteration of the organs 
designed for the defense of the organism against 
the poisons it manufactures spontaneously. Bou- 
chard has demonstrated that 500 grams of blood 
taken from a uremic subject contain 8 grams of 
extractive matters: i. e., about the same amount 
as is eliminated normally by the kidneys during 
24 hours. The attempt has been made in cerebro- 
spinal meningitis to clear the blood by venesection 
of all the toxic substances accumulating in it; 
and favorable results have been obtained with 
venesection, combined with the injection of salt 
solution, in diplococcic toxemia, especially in 
regard to the complicating hyposystolic phenom- 
ena, although these facts are not yet fully estab- 
lished. In uremic intoxication, an amount vary- 
ing from 500 to 1000 c.c. is withdrawn. The 
simultaneous injection of salt solution allows 
greater quantities of blood to be withdrawn. See 
Infusion of Saline Solutions. 
Baccelli reports that he has seen most remarkable 
results follow venesection, especially in capillary 
bronchitis and acute nephritis. He explains its 
action in the latter case by the fact that the per- 
ipheral pressure of the effusion in inflammation of 
Bowman's capsule compresses the small blood- 
vessels and retards the circulation through the 
delicate apparatus of the glomerulus, from which 
the entire functional economy of the kidney suffers; 
the epithelium undergoes fatty degeneration, and 
the urine diminishes in quantity, with symptoms 
of progressively increasing toxemia. He has 
saved and even secured complete regeneration of 
the kidney in many cases of this nature by open- 
ing a vein in the foot. 
VENOM.-See Bites and Stings (Snake-bites). 
VENOUS INFUSION.-See Infusion of Saline 
Solutions. 
VENOUS INJECTION.-See Intravenous In- 
jection. 
VENTILATION.-The dilution and removal of 
all impurities that collect in the air of inhabited 
rooms, the most common of which is CO2, the 
presence of which may be tested for by Lange's 
method. It consists of shaking, in a bottle full of 
the air to be tested, 1/2 of an ounce of clear fresh 
lime-water. If the air contains 7 parts to 1000 of 
CO 2, a turbidity of the fluid will occur. 
In hospitals the fundamental principle of venti- 
lation observed is that each adult person confined 
in a space of 1000 cubic feet requires 3000 cubic 
feet of fresh air an hour in order to prevent the 
proportion of carbon dioxid in the room from 
rising above 0.06 percent. This estimate is based 
on the fact that each adult expires, on the average, 
0.6 of a cubic foot of carbon dioxid an hour. 
Ventilation may be natural, due to the forces 
constantly acting in nature, or artificial, the result 
of measures introduced by man. The former is 
brought about by the agency of the wind and by 
diffusion, or the power that gases of different 
densities possess of mixing with one another. 
Artificial ventilation is brought about either by 
extracting the foul air from the room, or by forcing 
pure air into the room, and is affected by means of 
fans, heat, gas, or steam. 
Natural ventilation is aided by means of tubes or 
shafts employed as inlets and outlets. The out- 
lets are guarded by cowls, which prevent the 
entrance of rain, increase the extracting effect of 
the wind, and check the tendency to dowm-draft. 
A most valuable agent in this ventilation is the VENTILATION 
VERATRUM VIRIDE 
chimney. Windows also may be utilized for the 
same purpose. 
The estimation of CO2 in the air may be made by 
the following methods: 
1. Minimetric method, when the proportion of 
CO2 is not less than 1 part to 1000. The analysis 
is made by the use of a solution of sodium carbon- 
ate with phenolphthalein as an indicator. 
2. Pettenkofer's method has for its basis the fact 
that if air containing CO2 is brought into contact 
with barium hydroxid in solution, a combination 
takes place between the barium and CO2 immedia- 
tely, and insoluble barium carbonate is precipitated. 
3. Szydlowski's method consists in comparing a 
given volume of the air to be tested with a sample 
of air from which CO2 has been removed; the 
difference of pressure is recorded by means of a 
mercurial column. 
4. Reiset's method calculates the amount of CO2 
in the air from the difference found between the 
titration of a given volume of barium water before 
and after the passage of the air through it. 
Methods of Ventilation.-There are various 
methods of securing ventilation, some of which 
are as follows: 
In the Auburn or Pentonville system of ventilat- 
ing prisons the cells are arranged in blocks of 
several tiers in height, and each block is surround- 
ed by an outer building, between the walls of 
which and the doors of the tiers of cells on each 
side there is an open corridor, not divided by floors 
corresponding to the floors of the several tiers. 
The air is drawn from this corridor into the cells. 
Boyle's ventilator is an arrangement of mica 
valves allowing air to pass out, but allowing no 
back-draft. 
Cooper's ventilator is a series of apertures in the 
glass of a window-pane arranged in a circle so as 
to be more or less completely closed by a circular 
disc having corresponding apertures and moving 
upon a central pivot. 
Ellison's ventilating bricks are bricks perforated 
with conic holes, and fixed in the walls, with the 
apices of the cone on the outside. They are not 
likely to produce a draft. 
Hinckes-Bird's method consists in placing a 
movable block of wood under the entire length of 
the lower window-sash. 
Louvred panes are a form of window-ventilation 
by which an upward direction is imparted to the 
incoming air. These panes take the place of one 
or more of the squares of glass, and may be either 
opened or closed. 
Me Kinnell's ventilator is a combined outlet and 
inlet ventilator, which is applicable in the case of 
upper rooms or rooms in single-story houses. It 
consists of two tubes, the one encircling the other, 
the inner acting as the outlet, and being fitted 
with a cowl. 
The Sheringham valve is a common form of 
inlet in windows or walls for the purposes of 
ventilation. The entrance to the opening in the 
wall is guarded by a strainer to keep out dust, 
while on the inside is a valved iron plate with 
closed sides and hinged at the bottom. This 
opening is usually placed near the ceiling. 
The Smead-Dowd system of ventilation is an 
artificial system of ventilation in which the out- 
lets are at the bottom of the sheeting along the 
floor-line, and open into spaces beneath the floor. 
These spaces are connected with flues, down which 
the air is drawn by the powerful action of the 
f urnace-chimney. 
Tobin's tube is another means of ventilation, the 
air from without entering through a hole in the 
wall and being conducted by an upright tube into 
the upper portion of the room. 
VERATRIN.-A mixture of alkaloids obtained 
from the seeds of Asagrcea officinalis. See 
Veratrum. It is an exceedingly poisonous local 
irritant, and is used mainly as an external applica- 
tion for neuralgia, gout, and rheumatism. Dose, 
1/50 to 1/10 grain. Two preparations for exter- 
nal use are official-Oleatum Veratrinae (containing 
2 parts of veratrin dissolved in 50 parts of oleic 
acid and olive oil to 100) and the Unguentum 
Veratrinae (containing 4 parts of veratrin and 6 
parts expressed oil of almond incorporated with 
90 parts of benzoinated lard). In practice, more 
than 6 parts of alcohol are necessary to dissolve 
the veratrin; chloroform and acetic acid are better 
solvents than alcohol. Veratrin is revulsant and 
parasiticide. When brought in contact with 
cutaneous surfaces, it is exceedingly irritating, 
producing a feeling of warmth, followed by a sense 
of tingling. 
In neuralgia, especially in tic douloureux, the 
ointment of veratrin, rubbed into the affected 
part until it causes a sense of tingling, is often 
productive of great relief. 
I|. Veratrin, gr. xxv 
Alcohol, 5 vj 
Glycerin, 5 ij. 
Paint along the course of the affected nerve 
with a camel's-hair brush twice daily. 
This should not be applied if inflammatory 
symptoms are present. Veratrin has been highly 
commended by some ophthalmic surgeons as a 
remedy in orbital neuralgia. It is applied to the 
temple and brow in the form of ointment, contain- 
ing from 1 to 4 grains to the dram, according to 
the degree of irritation desired and the sensitive- 
ness of the skin. The proportion in the official 
ointment is 1 part in 26.5. Great care is necessary 
to keep it out of the eye, as it causes a violent 
and persistent conjunctivitis. The oleate (1:50, 
U. S. P.) is an excellent preparation. It is doubt- 
ful whether, as an external application, this drug 
has any therapeutic effect that cannot be attributed 
to the counterirritation it produces. 
VERATRUM VIRIDE (Hellebore).-The dried 
rhizome and roots of Veratrum viride, American 
hellebore, or veratrum album, white hellebore. 
They contain the alkaloids jervin, pseudojervin, 
and rubijervin; but veratrum viride contains also 
veratrin {cevadin), and veratrum album contains 
also protoveratrin, protoveratridin and other alka- 
loids. Dose, 1 to 3 grains. 
Asagrcea officinalis, veratrum sabadilla, cevadilla, 
is the source of the official veratrin, and is a 
mixture of alkaloids. It contains the alkaloids VERMIFORM APPENDIX 
VIABILITY 
veratrin (cevadin), cevadillin, sabadin, sabadinin, 
and another base known as Wright's veratrin. It 
is a violent emetic and cathartic, and is actively 
poisonous; it is now little used, except as an insect 
powder. For this use it is highly valued, as it 
destroys many insects which the ordinary buhach 
does not affect. Veratrum viride is a powerful 
depressant of the heart and a paralyzant of the 
spinal cord. Its action is similar to that of acon- 
ite, but is regarded as inferior. The chief use is 
as a circulatory sedative in acute, sthenic, or 
dynamic inflammations. It is highly esteemed in 
puerperal fevers, pneumonia, pleurisy, hepatitis, 
peritonitis, cerebritis, and aneurysm. It is con- 
traindicated in conditions of exhaustion or 
depression, or if vomiting is feared. 
In poisoning by veratrum viride cardiac stimu- 
lants, atropin, strychnin, and external heat are 
indicated. V., Flext. Dose, 1 to 4 minims. 
V., Tinct., 10 percent. Dose, 10 to 30 minims. 
VERMIFORM APPENDIX.-See Appendicitis. 
VERMIFUGE.-See Anthelmintics, Worms. 
VERONAL.-Diethyl Malonylurea.-It is a 
very efficient and rapid hypnotic in doses of 8 to 
10 grains, given in some hot liquid. It induces 
a practically normal sleep, does not affect the 
heart, circulation or kidneys, and is free from after- 
effects. It is particularly efficient when mixed 
with sulphonethylmethane (trional) in the pro- 
portion of two parts of the former to one of the 
latter (e. g., gr. viii with gr. iv). 
VERONAL-SODIUM.-Sodium diethyl-barbi- 
turate. Its action and dosage are the same as 
veronal, but it is said to act more rapidly by 
reason of its greater solubility. 
VERRUCA.-See Warts. 
VERSION.-See Fetus (Positions and Presenta- 
tions). 
VERTIGO (Dizziness).-A subjective state in 
which the individual affected, or the objects 
about him, seem to be in rapid motion, either of a 
rotatory, circular, or to-and-fro character. 
The etiology of an attack of vertigo depends 
upon the particular variety. 
Ocular vertigo results from the paresis of one or 
more of the ocular muscles, or from eye-strain. 
Aural or auditory vertigo, or Meniere's disease, 
results from disease of the semicircular canals and 
cochlea. Meniere's Disease (q. v.), properly 
so called, is a sudden severe vertigo, the result 
either of a hemorrhage or of a serous or purulent 
exudation into the semicircular canals. 
Gastric vertigo is the most common variety, 
and results either from stomachic or intestinal 
dyspepsia, disordered hepatic function or constipa- 
tion. The mechanism of the vertigo is complex. 
There are two factors; one consists in the toxic 
effect of the imperfectly oxidized materials that 
accumulate in the blood; the other is reflex. 
An impression made on the end-organs of the pneu- 
mogastric nerve in the stomach is reflected over 
the sympathetic ganglia. 
Nervous vertigo is associated with migraine and 
with sick or nervous headache, and is also caused 
by physical or nervous excesses and by the im- 
moderate use of tea, coffee, alcohol, and tobacco. 
It is also a result of many of the organic diseases 
of the brain. 
Senile vertigo is the result of the disordered cere- 
bral circulation resulting from changes in the heart 
and vessels. 
Symptoms.-In all varieties of vertigo the 
symptom of a sensation of objects moving around 
the patient, or of the patient moving around ob- 
jects that remain stationary, is present in some 
degree. The attack of giddiness comes on sud- 
denly, with indistinctness of vision and slight 
confusion of the thoughts. The patient may 
fall, unless he grasps something to steady himself. 
Nausea and vomiting, and cardiac palpitation 
with tinnitus aurium, are often associated with 
the vertiginous sensations. There is no loss of 
consciousness. 
In ocular vertigo the attack is usually the result 
of reading, writing, sewing, or other close applica- 
tion of the eyes, the ordinary symptoms of vertigo 
being preceded by headache, nausea, specks 
before the eyes, and pain in the eyeballs. 
The prognosis is favorable in ocular and gastric 
vertigo. Unless the result of organic disease, 
the prognosis is favorable in nervous vertigo. In 
auricular vertigo the prognosis is fair, but in 
genuine Mdni&re's disease the prognosis is unfavor- 
able, as it is also in senile vertigo. 
Treatment.-For ocular vertigo rest for the eyes 
is necessary and properly adjusted glasses are 
required. For cases of Meniere's disease rest in 
the recumbent position and the use of full doses 
of quinin, 10 to 15 grains daily for a long period, 
as suggested by Charcot. 
For gastric vertigo a careful regulation of the 
diet is indicated. At the beginning of the treat- 
ment it is often of great advantage to place the 
patient on an exclusively milk diet, gradually 
widening the variety of food as improvement 
occurs. In these cases a course of arsenic is often 
serviceable. If the digestion is torpid, the use of 
tincture of nux vomica is indicated. If the bowels 
are constipated, benefit is obtained from fluid- 
extract of cascara sagrada. 
For nervous vertigo the removal of the exciting 
cause and the use of such remedies as iron, quinin, 
and strychnin, either alone or variously combined, 
are demanded. For senile vertigo a highly nutri- 
tious but easily digested diet, the use of pure 
stimulants, and a course of mercuric chlorid, or 
arsenic with tincture of nux vomica, are advisable. 
In all varieties of vertigo the habits of the patient 
must be most abstemious, excluding tobacco, 
tea, coffee, highly seasoned foods, malt liquors, 
and alcohol unless particularly indicated. 
VESICAL CALCULUS.-See Bladder (Stone). 
VESICANTS.-See Counterirritation. 
VIABILITY.-Ability to live; applied to a child 
at the time of birth. The term indicates the ca- 
pacity for independent existence. Viability has 
chiefly to be determined by the age of the fetus and 
by its condition as regards formation, health, and 
strength. It also depends in some measure upon 
the season of the year and upon the climate in 
which the child is born. 
The earliest period at which a child can be VIABILITY 
VINCENT'S ANGINA 
born, in temperate climates, and be capable of 
living and of reaching maturity, is usually re- 
garded as about 7 months, or 210 days. Cases 
are on record of children born at the sixth month 
who were reared. 
Signs of maturity are: Strong movements and 
cries directly after birth; the body is of a clear 
pink or red color, and is covered with sebaceous 
matter; the mouth, nostrils, eyelids, and ears are 
open; the nails reach, if not extend beyond, the 
finger-tips; the hair and eyebrows are completely 
developed, the hair of the head being about an 
inch long; the skull is somewhat firm, the fontanels 
are not far apart; the four portions of the occipital 
bone are distinct, and the external auditory meatus 
is cartilaginous; the testicles have passed the in- 
guinal ring; there is meconium at the end of the 
large intestine or it is freely discharged and urine is 
passed; there is a point of ossification in the center 
of the cartilage at the lower end of the femur. 
The power of suction has developed, as evidenced 
by placing a nipple or the finger in the mouth. 
The ordinary length of the child is from 16 to 20 
inches and the weight is from 4 to 7 pounds. 
Between the sixth and seventh months the 
length of the fetus is from 10 to 14 inches. The 
skin is of a dusky red color and is covered with 
down and sebaceous matter; the pupillary mem- 
branes are disappearing and the nails do not reach 
to the ends of the fingers. Meconium may be found 
at the upper end of the large intestine and the 
testicles are situated near the kidneys. Points of 
ossification may be found in four divisions of the 
sternum and in the astragalus. The center of 
the body at the sixth month is at the lower end of 
the sternum, while at the seventh month it is a 
little below the sternum. The length of the child 
at eight months is from 14 to 18 inches; its weight 
is from 3 to 5 1/2 pounds. The skin is rosy and 
is covered with fine short hairs, with distinct 
sebaceous envelope; the nails reach to the ends of 
the fingers, and the pupillary membranes have 
entirely disappeared; the testicles have descended 
into the inguinal ring, and there is a point of ossi- 
fication in the last vertebra of the sacrum. The 
middle of the body is nearer to the umbilicus than 
to the sternum.. 
The signs of immaturity are: The head is out of 
proportion to the body; the body center is high up; 
the pupillary membranes are present; the testicles 
are undescended and the genital organs are of a 
deep red color; the skin is intensely red, mottled, 
and coated by a downy covering, sebaceous matter 
being absent; the nails are imperfectly formed. 
Movements are feeble; there is inability to suck; 
artificial heat is necessary; sleep is almost unbroken; 
the discharges of meconium and of urine are 
infrequent and imperfect; and the mouth, nostrils, 
and eyelids are closed. 
The tests of live birth are appended: 
Breslau Test.-If the intestines and stomach of 
the infant were found to float in water on removal 
from the body it was thought to be proof that the 
child was born alive. This test is of no value. 
Hydrostatic Test.-Suggested by Raygat. It 
consists in placing the lungs in water and noting 
their specific gravity. If inflation has occurred, 
they will float. This test is valuable. 
Ploucquet's Test.-This consists in estimating 
the ratio of the weight of the lungs to the weight 
of the body of the child. Ploucquet laid down this 
rule: that before respiration the weight of the lungs 
compared to the weight of the body was in the 
ratio of 1:70, and that after respiration it was in 
the ratio of 1:35. The test is of but slight value. 
Static Test.-Also called FoderFs or Schmidt's 
test. This consists in ascertaining the absolute 
weight of the lungs, and comparing this weight 
with the average lung weights of still-born children 
and of children who have died soon after birth. 
Fodere fixes the weight of the lungs of still-born 
children born at term at 480 grains (1 ounce), and 
960 grains (2 ounces) as the weight of the lungs 
soon after breathing has been established. This 
test is also of but slight value. 
VIBURNUM.-V., opulus, cramp bark. Dose, 
10 to 45 grains. Dose of the fluidextract, 10 to 
45 minims. This drug is valued as a remedy for 
uterine and abdominal, pains. V. prunifolium, 
black haw, is also derived from the bark of a 
shrub of the same natural order. It contains 
tannic, oxalic, citric, and malic acids, and sul- 
phates and chlorids. It also contains 2 resins, 
viburnin and viburnic acid, the latter of which is 
identical with valeric acid. 
The fluidextract (dose, 10 to 45 minims) is the 
only preparation. The drug is considered a 
nervine, and is antispasmodic, astringent, diuretic, 
Spirillum of Vincent and the Fusiform Bacillus; 
Other Organisms are also Present.-(.Rosenberger and 
Coplin.) 
and tonic; it is especially useful in preventing 
abortion, in the nervous diseases of pregnancy, 
and in spasmodic dysmenorrhea. It may be 
administered with cannabis indica, with morphin 
and other nerve sedatives, and with aromatics. 
Nausea and vomiting are often excited by it. 
There is no exact observation concerning its 
physiologic action. 
Liquor sedans is a utero-ovarian sedative and 
anodyne. Each fluidounce contains of black haw 
and golden-seal, each 60 grains; Jamaica dogwood, 
30 grains; aromatics, a sufficient quantity. 
VINCENT'S ANGINA.-A form of pharyngitis or 
tonsillitis that closely simulates diphtheria. A VINEGAR 
VISION, TESTS 
fusiform bacillus and a spirillum have been 
demonstrated. 
VINEGAR (Acetum).-An impure, dilute acetic 
acid produced by acetous fermentation of wine, 
cider, or other fruit-juice. In pharmacy a solution 
of the active principles of certain drugs in dilute 
acetic acid. There are two official vinegars: 
Acetum Opii (vinegar of opium) (black drop); con- 
taining opium, 10 percent; nutmeg, 3 percent; 
sugar, 20 percent. It is used as a sedative. Dose, 
2 to 15 minims. Acetum Scillae (vinegar of squill), 
containing 10 percent squill. It is used as an 
expectorant. Dose, 15 to 45 minims. See Acetic 
Acid. 
VINUM (Wine).-The fermented juice of fruits, 
especially that of grapes. White wines are made 
from the pulp; red wines from the pulp and skins, 
the latter yielding the coloring-matter. 
When medicated, wines (vina) are practically the 
same as tinctures. The menstruum directed to be 
used is the official white wine (vinum album), 
which should contain from 7 to 12 percent by 
weight of absolute alcohol. It is, however, rein- 
forced by the addition of alcohol to the amount 
of 5 to 17 1/2 percent in all the medicated wines. 
In the two ferric wines the alcoholic reinforcement 
is in the shape of the tincture of sweet orange peel. 
The wine of coca is made with red wine. The 
official wines are 10 in number, 2 of which are not 
medicated, namely white wine and red wine. 
Vinum Album (White Wine).-An alcoholic 
liquid, made by fermenting the juice of fresh 
grapes, the fruit of Vitus vinifera freed from seeds, 
stems, and skins, and subjected to the usual cellar- 
treatment for fining and aging. A pale, amber- 
colored or straw-colored liquid, having a pleasant 
odor free from yeastiness, and a fruity, agreeable, 
slightly spirituous taste, without excessive sweet- 
ness or acidity. 
Vinum Rubrum (Red Wine).-An alcoholic 
liquid, made by fermenting the juice of fresh, red- 
colored grapes, the fruit of Vitus vinifera, in pres- 
ence of their skins, and subjected to the usual 
cellar-treatment for fining and aging. A deep red 
liquid, having a pleasant odor free from yeastiness, 
and a fruity, moderately astringent, pleasant and 
slightly acidulous taste, without excessive sweet- 
ness or acidity. 
There are eight medicated wines official in the 
U. S. P., as follows: 
See Wine. 
VIOFORM.-lodochloroxyquinolin. Ni o f o r m. 
Antiseptic and hemostatic in action, it is recom- 
mended as an ideal substitute for iodoform. 
VIRUS, VACCINE.-See Vaccination. 
VISCEROPTOSIS. (Glenard's Disease, Enterop- 
tosis, Gastroptosis, Splanchnoptosis).-By reason 
of relaxation of the ligaments, the organs in the 
abdomen are found below their normal position. 
Loss of elasticity of the abdominal muscles is a 
predisposing cause. This may result from gastro- 
intestinal autointoxication, from repeated preg- 
nancies, from pressure of clothing, from hemor- 
rhages. In some cases only one organ may be 
displaced. 
Symptoms.-Nervous dyspepsia, anorexia, con- 
stipation or diarrhea may be found, although 
some cases present no symptoms. There may be 
abdominal distention, eructations, pains after 
eating, nervous symptoms such as headache, 
vertigo, insomnia, emaciation, or chlorosis is 
frequently found. 
Treatment.-If symptoms exist, they may be 
relieved by a wide bandage or other appliances 
(such as pads, springs, trusses, or corsets). Lavage 
is useful in gastroptosis. For permanent relief 
operation is necessary. 
VISION, DEFECTS.-See Amblyopia, Blind- 
ness, Field of Vision. 
VISION, TESTS. Test-cards.-It has been dis- 
covered that the smallest retinal image that can be 
perceived at the macula corresponds to a visual 
angle of 1'. The visual angle is the angle included 
between two lines drawn from two opposite edges 
of the object through the nodal point. Following 
this principle, test-types have been constructed in 
such a manner that every letter is so made that 
when at its proper distance it subtends an angle 
of 5'. It is well to have two series of letters, to 
avoid doubtful results from the patient learning 
the positions of the letters on a single card. 
The mode of procedure in determining the acuity 
of distant vision with test-types is as follows: 
The patient is placed with his back to the light in 
front of the test-cards, which should be hung at a 
distance of 5 or 6 meters, and should be well illum- 
inated by artificial light from a reflector, about 2 
feet away and to one side. The eye not under 
examination is then covered, and the patient is 
asked to read the lowest line possible. If, seated 
at 6 meters' distance, he reads the line marked 6 
meters, his visual acuity is expressed by the frac- 
tion 6/6; if he reads the line marked 4 meters, he 
has remarkable acuteness of vision, and -we ex- 
press it by the fraction 6/4; if he is amblyopic, 
or ametropic he will not be able to read the 
6-meter letters, and may possibly read only the 
line marked 15 meters, when his visual acuity 
is expressed by the fraction 6/15. Some sur- 
geons prefer to use feet instead of meters in 
their estimations, and to seat their patients 
at about 20 feet from the card, expressing the 
visual acuity by using 20 for the numerator 
and the foot-number of the card seen as the 
denominator. It sometimes happens that the 
patient is not able to read any letter on the card 
Title. 
Active 
Constituents. 
Properties and 
Dose. 
Vinum: 
Antimonii 
Tartar-emetic, 0.4 
percent. 
Expectorant (15 
minims). 
Cocae 
Coca, 6.5 percent. 
Stimulant (4 
drams). 
Colchici seminis.. 
Colchicum seed, 10 
percent. 
Diuretic (30 min- 
ims). 
Ergot® 
Ergot, 20 percent. 
Emmenagogue, par- 
turient (2 drams). 
Ferri 
Cit. iron and am- 
mon., 4 percent. 
Tonic, (4 drams). 
Ferri amarum... . 
Cit. iron and quin- 
in, 5 percent. 
Tonic (2 drams). 
Ipecacuanh® 
Fldext. ipecac, 10 
percent. 
Expec t o r a n t (15 
minims). 
Opii 
Granulated opium, 
10 percent. 
Sedative (8 min- 
ims). VITILIGO 
VOICE IN DIAGNOSIS 
at 6 meters' distance. In such a case he should 
gradually approach the card or the card should be 
brought toward him, until the top letter is dis- 
tinguished. This distance is noted, and serves 
as the numerator in the fraction of visual 
acuity. 
With illiterates it is best to use a regular illiter- 
ate card, consisting of lines shaped like the plain 
capital letter E. The patient is asked to tell 
which way the prongs of the E point-upward, 
downward, to the right, or to the left. More diffi- 
cult are the Burchardt dots for counting. These 
cards are constructed on the Snellen principle. 
For foreigners special cards have been constructed. 
The German and Hebrew letters are often of value 
in hospital work. 
Testing Near Vision.-The test-cards usually 
employed to estimate the accommodation are 
after the model of Jaeger, and are merely printers' 
types of various sizes. These cards have the 
advantage of closely resembling the work ordinar- 
ily done by the eye in reading, but have the dis- 
advantage that they are not arranged on any 
scientific plan. It is possibly better to use cards 
in which each word is composed of several letters 
constructed in strict conformity with the Snellen 
basis of letter-formation. 
The mode of procedure with the near type is to 
find the furthest and nearest point at which the 
smallest recognizable type is readable. In presby- 
opes it is necessary to use a convex lens of a 
strength varying with the age of the patient. 
Each eye should be examined separately. See 
also Blindness (Tests). 
VITILIGO (Leukoderma).-An acquired pig- 
mentary affection, characterized by variously 
sized and shaped whitish patches with hyper- 
pigmented borders. 
Symptoms.-The condition manifests itself as 
rounded, oval or irregular, milk-white or pinkish- 
white spots, which tend to spread slowly or 
rapidly, at times coalescing and producing large 
patches. These are smooth, soft, sharply defined, 
and neither elevated nor depressed. The sur- 
rounding skin shows increased pigmentation, 
being usually brownish-yellow in color. The 
hairs upon the affected areas may or may not turn 
white. The disease progresses slowly, be- 
coming conspicuous only after a duration of 
years. In rare cases the affection may involve 
the greater part or, indeed, the whole of the body. 
Vitiligo lasts throughout life. The eruption may 
occur upon any portion of the cutaneous surface, 
although it is prone to elect the backs of the hands 
and the trunk. There are no subjective symp- 
toms. Disfigurement is the sole inconvenience. 
The affection is frequent in negroes, in whom it 
produces a most striking appearance. 
Etiology.-Vitiligo occurs in adult life. In 
many cases there is no ascertainable cause. It is 
due, in all probability, to a disturbance of innerva- 
tion. It is occasionally associated with morphea, 
alopecia areata, and exophthalmic goiter. 
Pathology.-The skin is normal, with the excep- 
tion of an unequal distribution of coloring-matter. 
In the white spots there is total absence of pigment 
whereas in the darkened borders the pigment is 
abnormally increased. 
Diagnosis.-Vitiligo is to be distinguished from 
chloasma, tinea versicolor, morphea, and leprosy. 
In both chloasma and tinea versicolor the 
patches are brown, whereas in vitiligo they are 
white. Furthermore, tinea versicolor is scaly, 
and the fungus is found in the scales. . Morphea 
shows structural alteration of the skin, and the 
patches in leprosy are anesthetic. 
Prognosis.-In rare cases spontaneous recovery 
has been observed, but the affection may be said 
to be practically incurable. 
Treatment is highly unsatisfactory. Duhring 
advises the long-continued administration of 
arsenic. Locally, lotions of corrosive sublimate 
or acetic acid, as recommended in chloasma, may 
be applied to the pigmented borders, with a view 
to dissipating the color and lessening the contrast. 
VITREOUS, DISEASES.-The corpus vitreum 
forms the principal part of the globe of the eye. 
It consists of 98.6 percent of water. The remain- 
der is composed of transparent fibers extending in 
all directions. Between these fibers are the com- 
partments in which the nearly pure water, or 
vitreous humor, is contained. The vitreous is 
pierced in an irregular sagittal direction by the 
central canal, about 2 mm. in diameter. In the 
embryonic state the hyaloid artery traverses this 
canal, and sometimes persists after birth. The 
vitreous is contained in a delicate membrane, 
called the hyaloid membrane. 
Hyalitis, or inflammation of the vitreous, is not 
an independent disease, but is generally associated 
with inflammation of the uveal tract, particularly 
of the ciliary body, which causes disturbances of 
nutrition. It is characterized by change in con- 
sistency and by partial disorganization. Opaci- 
ties, in the form of threads, clouds, or separate 
flocculi, are seen and cause subjective visual dis- 
turbance; and, provided the medium is suffi- 
ciently clear, are detected by the ophthalmoscope. 
The treatment is constitutional, and under all 
circumstances should be directed to the cause. 
It consists chiefly of mercurials and iodids and of 
leeches to the temple. 
VITRIOL.-See Sulphuric Acid. 
VOICE IN DIAGNOSIS.-The voice is the sound 
produced by the vibration of the vocal bands, 
modified by the resonance organs. It is of great 
value in diagnosis. 
The Voice in Health.-If the ear is applied over 
the larynx or trachea of a healthy person, and he is 
directed to count "twenty-one, twenty-two, 
twenty-three," in a uniform tone and with moder- 
ate force, there is perceived a strong resonance 
with a sensation of concussion or shock, and a 
sense of vibration, thrill, or fremitus, the voice 
seeming to be concentrated and near the ear. 
Often the articulated words are distinctly trans- 
mitted (laryngophony). The sounds thus heard 
are termed the normal laryngeal resonance. 
If the ear or stethoscope is applied over the 
third rib anteriorly on either side of the chest of a 
healthy person, and he is directed to count "twenty- 
one, twenty-two, twenty-three," in a uniform VOICE IN DIAGNOSIS 
VOMITING 
tone, with moderate force, a confused distant hum 
is perceived, of variable intensity, accompanied 
by more or less vibration, thrill, or fremitus, most 
distinct in adults, but notably weaker in women 
than in men. This sound is termed the normal 
vocal resonance. 
If the ear or stethoscope is applied over the third 
rib anteriorly of a healthy person, and he is directed 
to whisper, in a uniform manner, the words "twenty- 
one, twenty-two, twenty-three," there is heard a 
sound corresponding closely in character to the 
sound of expiration over the same region during 
the act of forced respiration; or, in other words, 
a feeble, low-pitched, blowing sound. This sound 
is termed the normal bronchial whisper, and is 
produced by the air in the bronchial tubes during 
the act of respiration. 
The Voice in Respiratory Diseases.-The normal 
vocal resonance, as heard over the third rib of the 
chest anteriorly on either side, may be altered in 
intensity: 
1. Diminished or absent. 
2. Increased or exaggerated. 
Or its resonance may be of the character of: 
3. Bronchophony. 
4. Pectoriloquy. 
5. Egophony. 
6. Amphoric voice. 
The vocal resonance may be diminished or 
feeble in bronchitis with free secretion, in pleurisy 
with effusion, or in complete consolidation of the 
lung structure and the bronchial tubes. 
The vocal resonance is absent in pneumothorax 
and in pleurisy with effusion. 
Exaggerated vocal resonance differs from the 
normal resonance in a slight increase of its density. 
It denotes a slight degree of solidification of lung 
tissue, and is chiefly of value in the diagnosis of 
tubercle. 
Bronchophony, or the voice concentrated near 
the ear, raised in pitch and in intensity, denotes 
complete consolidation of the pulmonary tissue 
in those parts in which the sound is abnormally 
present. 
Pectoriloquy is complete transmission of the 
voice to the ear, the articulated words being dis- 
tinctly recognized. It has a close resemblance to 
the resonance heard over the larynx in health. 
Its presence indicates either a pulmonary cavity 
or more complete consolidation-in other words, 
an exaggerated bronchophony. 
Egophony is a modification of bronchophony, con- 
sisting in tremulousness of the voice, its character 
being nasal or bleating, somewhat suggestive of 
the cry of a goat. When heard, it may be con- 
sidered a sign of pleurisy with slight effusion or of 
pleuropneumonia. 
Amphoric voice, or "the echo," as it is some- 
times called, is a musical sound, of a somewhat 
hollow, metallic character, like that produced by 
blowing into an empty bottle. It is sometimes 
produced in large cavities within the lung, but is 
especially incident to pneumothorax. 
Increased bronchial whisper is a sound in which 
the whispered words are abnormally intense and 
are higher in pitch than in the normal bronchial 
whisper. It has the same significance as exag- 
gerated vocal resonance. See Chest (Examina- 
tion). 
The Voice in Other Morbid Conditions.-There 
are many other changes of the voice that may occur 
in different conditions, and that may be of value 
as indicating morbid states. There are differences 
in the cry of infants-the normal cry, indicating 
hunger; the cry of irritability or pain (see Infantile 
Symptoms) ; the changes with respiratory disorders. 
Skene notices the morbid state of the voice, in- 
dicating circulatory disturbances, cases of heart 
disorder, and Bright's disease, including hyper- 
emia of the vocal cords, lowering and modifying 
the tone and quality. Anemia raises the pitch of 
the voice, and a concealed hemorrhage may be 
detected by one whose attention has been called to 
this point. He refers to the importance of noticing 
the condition of the voice as indicating the nervous 
state before performing major operations, and also 
to its testimony as showing the amount of shock 
after an operation. The voice is also of value as 
indicating the reaction from this condition, and 
sometimes is the first and only symptom. The 
voice as an indication of apathetic conditions is also 
of importance, and frequently is of very valuable 
prognostic significance. There is a liability to take 
this apathetic tone as an indication of content- 
ment, a wrong diagnosis resulting. Skene speaks 
of the expression of the voice after abdominal 
operations, and of the peculiar voices of the in- 
sane. The last, however, he does not venture 
to remark on extensively. He says that it is 
necessary, in order thoroughly to utilize this 
feature in diagnosis, to have had considerable 
experience, and to possess a normal sense of hearing 
and ready appreciation of the varieties of quantity 
and characteristics of sound; but especial refine- 
ment of the sense is not necessary. 
VOICE, LOSS.-See Aphonia, Dysphonia, 
Laryngitis. 
VOLVULUS.-See Intestinal Obstruction. 
VOMITING.-Vomiting is produced: (1) By 
local causes, such as irritation of the stomach 
from disease of the organ (cancer, ulcer, dyspepsia, 
gastritis), or from the ingestion of certain varieties 
of food or drugs; (2) by reflex causes, such as 
cerebral disease, disease of the spinal cord, heart- 
lung-, or kidney-disease, abdominal tumors, 
pregnancy, intestinal obstruction, peritonitis, 
general nervousness, and constipation; (3) by 
infectious diseases, such as scarlet fever, typhoid 
fever, cholera, small-pox, yellow fever, malarial 
fever, and tuberculosis. 
Character of Vomitus. Solid or Liquid Food.- 
Solid food may be ejected from the stomach im- 
mediately after it has been taken, as in certain 
varieties of dyspepsia, and after the ingestion of 
partly decomposed food. 
Acid Vomiting.-This variety usually occurs in 
cases of dyspepsia with hyperacidity attended by 
constipation. The fluid is generally thin and highly 
acid, giving rise to pyrosis, or "water-brash." 
Excessive flatulence is usually present, attended 
by heartburn. In many cases the condition is VOMITING OF PREGNANCY 
VULVA, DISEASES 
relieved by correcting constipation. See Flatu- 
lence, Constipation, Gastric Neuroses. 
Mucous Vomiting.-In this variety the vomitus 
is, for the most part, composed of thick, glairy 
mucus; it occurs in acute and chronic gastritis. 
Bilious Vomiting.-Bile may find its way into 
the stomach when reversed peristalsis occurs, as 
in obstruction of the bowels in the early stages, 
in impaction of a gall-stone, and in malarial fever 
or yellow fever. 
Fecal vomiting occurs in the later stages of in- 
testinal obstruction. 
Bloody vomit (hematemesis) is seen in gastric 
cancer, in ulceration of the stomach, in yellow 
fever, and in some cases of cirrhosis of the liver. 
Purulent vomit is due to rupture of an abscess 
into the stomach or esophagus. 
Profuse Vomiting.-Profuse vomiting is gener- 
ally due to gastric dilatation, as seen in cases of 
gluttony, prolonged debauch, and gastric cancer. 
In most instances it occurs a long tme after eating. 
The material usually contains sarcinae ventriculi if 
due to cancer, and sometimes if due to ulcer of the 
stomach. 
Vomiting due to Cerebral Causes.-Vomiting 
due to intracranial disease generally occurs soon 
after the food has been taken, and is usually 
unattended by premonitory feelings of nausea or 
discomfort. Gowers states that when this variety 
of vomiting is accompanied by persistent pain in 
the head, and when it occurs with increased fre- 
quency, it should always give rise to suspicion of 
cerebral disease. In such cases optic neuritis 
would point directly to intracranial disturbance. 
Vomiting in Infectious Diseases.-Vomiting 
occurs during the onset of most of the infectious 
diseases, especially in children. 
Treatment of Vomiting.-No well-defined rule 
can be laid down that would apply to all varieties 
of vomiting. Persistent effort must therefore 
be made to find the exciting cause of the act 
of vomiting, and it should be treated upon 
general principles. Cold applications and ice 
by the mouth will allay the irritability of 
the stomach. In cases of collapse heat may 
be used locally. Cocain may be administered in 
severe cases. The usual treatment of the vomit- 
ing of indigestion or debauch is the administration 
of calomel in small doses (1/10 grain every hour), 
followed by a purgative. Bismuth subnitrate, 
cerium oxalate and validol have been recommended. 
The immediate diet must be very scant and should 
be chiefly liquid. See Emetics, Antiemetics. 
VOMITING OF PREGNANCY.-There is a 
physiologic, an exaggerated, and a pernicious 
vomiting in pregnancy. The first two forms are 
of minor importance; the last is a serious affection, 
requiring active treatment. See Pregnancy 
(Pernicious Vomiting). 
VULVA, DISEASES.-Inflammation of the vulva, 
or vulvitis, is usually the result of gonorrhea. It 
may be due to irritating discharges from other 
conditions, such as cancer of the cervix, corporeal 
endometritis, or a vesicovaginal fistula. In 
children it is seen not infrequently as the result of 
uncleanliness. 
The symptoms are pain and burning of the 
vulva with more or less discharge. The parts are 
inflamed and somewhat edematous. 
Treatment consists in rest in bed and in frequent 
cleansing of the vulva with boric acid solution 
(1 dram to 1 pint). As the acute symptoms 
subside the inflamed areas may be painted with a 
2 percent solution of nitrate of silver. This 
should be repeated daily until all evidence of the 
disease has subsided. 
Should the inflammation become localized in 
the mucous or sebaceous glands of the vulva, the 
affected glands should be punctured and cauter- 
ized with pure carbolic acid. 
Hematoma of the vulva is usually a complica- 
tion of labor, and is the result of subcutaneous 
rupture of a vein. It generally occurs as the result 
of other forms of traumatism. 
Treatment consists in thorough cleanliness of 
the parts and in slight compression of the tumor, 
which will cause its rapid absorption. Should 
infection occur, the tumor should be incised and 
the blood-clot turned out, and the cavity should 
be irrigated and packed with gauze. 
Papilloma of the vulva is usually the result of 
venereal disease. It is sometimes caused by 
uncleanliness, and may exist as a complication of 
pregnancy. Papillomata occur usually in two 
forms-as small,, isolated, warty growths, or as 
distinct cauliflower-like tumors. 
The treatment is excision. The small warts 
may be snipped oft with scissors, after which their 
bases should be cauterized. The larger growths 
should be excised and the wounds should be closed 
with interrupted sutures. 
Pruritus.-Itching of the vulva may be due to 
a variety of causes. It not infrequently occurs as 
the result of irritating discharges, or it may be due 
to tubal or ovarian disease or to uncleanliness. 
Diabetic urine may cause this disease, or it may 
exist without any ascertainable cause, when it is 
called idiopathic pruritus. The intense itching of 
the vulva causes scratching and rubbing, which are 
finally followed by irritation, inflammation, and 
discharge. 
Treatment consists in relieving the cause. If 
it is due to discharge from the uterus, measures 
should be taken to prevent this. A vaginal 
tampon should be worn and perfect cleanliness 
should be practised. Diabetic urine should be 
prevented from coming in contact with the vulva, 
and the patient should exercise care in thoroughly 
drying herself after urination. Local applications 
will sometimes be of value. One of the best is: 
1$. Tincture of opium, 
Tincture of iodin, 
Tincture of aconite, 
each, 5 v 
Carbolic acid, 5j. 
This may be applied to the parts 2 or 3 times 
daily. 
The following ointment may be employed: 
1$. Menthol, 5 j 
Lanolin, § ij. 
In some cases cauterization with pure carbolic 
acid may give relief. WAHOO 
WATER 
w 
WAHOO.-See Euonymus. 
WALCHER'S POSITION.-See Gynecologic 
Examination (Table of Postures and Positions). 
WARBURG'S TINCTURE.-See Quinin. 
WARTS (Verrucae).-Pinhead-sized to bean- 
sized circumscribed elevations of the skin due to 
epidermal and papillary hypertrophy. 
Symptoms.-Various forms of warts are distin- 
guished : 
Verruca Vulgaris.-This is the common wart seen 
upon the hands. It is a pea-sized, rounded, rough 
or smooth, broad-based elevation, yellow or 
brownish in color. It may occur singly or in 
numbers. 
Verruca Plana.-This is distinguished from the 
ordinary wart by being flat and broad. Flat warts 
are pea-sized or fingernail-sized, but slightly 
elevated, and of a brownish or blackish color. 
They occur in numbers, usually upon the backs 
of elderly individuals (verruca senilis). Occa- 
sionally, numerous small flat warts occur upon 
the face. 
Verruca Filiformis.-These warts are slender, 
thread-like outgrowths, about 1/8 of an inch in 
length, occurring chiefly upon the face, eyelids, 
and neck. 
Verruca Digitata.-These are slightly elevated 
pea-sized to fingernail-sized excrescences, with 
numerous digitations branching out from the base. 
The scalp is the most common site. 
Verruca Acuminata (Pointed Condyloma, Vene- 
real Warts).-These are pinkish or reddish, sessile 
or pedunculated, pointed vegetations occurring 
about the mucocutaneous surfaces (penis, labia, 
anus, mouth, etc.) of young individuals. Occur- 
ring upon the genitals, they are bathed in an 
offensive puriform secretion. These warts grow 
rapidly, not infrequently attaining the size of an 
egg. They bear at times a strong resemblance to a 
raspberry, to cauliflower, or to a cockscomb. 
Etiology.-It is probable that at least some 
forms of warts are due to microorganisms, and 
that they are autoinoculable and contagious. 
Venereal warts are caused by contact with irritat- 
ing secretions containing, in all probability, the 
causal microorganisms. 
Pathology.-Warts consist of a hyperplasia of 
the papillae of the corium and the overlying layers 
of the epidermis. A vascular loop is found in the 
center of each wart. In the acuminate variety 
the connective tissue and vascular hypertrophy is 
marked, while the horny layer is but slightly 
hyperplastic. 
'Treatment.-Warts may be removed by caus- 
tics, excision, erasion, or electrolysis. The best 
caustics to be employed are nitric acid, caustic 
potash, chromic acid, or glacial acetic acid. 
These should be cautiously applied from time to 
time until the disappearance of the wart. An 
excellent method is to scrape away the wart with 
a curette and to apply the stick of nitrate of silver to 
the base. 
Salicylic acid in collodion or alcohol is often 
successful in causing the disappearance of warts. 
I|. Salicylic acid, 5 j 
Alcohol, 3 j • 
Apply 2 or 3 times a day. 
Or- 
3- Salicylic acid, 5 j 
Collodion, ,3j. 
Apply twice a day. 
The use of a 1:500 corrosive sublimate solution 
is sometimes efficacious, as is also an alcoholic 
solution of resorcin, 30 grains to the ounce. 
Filiform or digitate warts may be snipped off 
with curved scissors, the base being subsequently 
cauterized. Venereal warts may be washed with 
solutions of alum, tannin, or chlorinated soda, and 
then dusted with calomel, or they may be cauter- 
ized with nitric, carbolic, or chromic acid. Clean- 
liness should be strictly enjoined. 
It has been claimed recently that chrysarobin is 
a specific for warts. The surface of the warts is 
carefully thinned with a sharp, fine glass-paper 
which gives better results than paring with a knife, 
as the patient is less afraid of injuring himself and 
can more conveniently handle the paper. Chrys- 
arobin may be applied either in a 10 percent solu- 
tion of the ordinary gutta-percha solution or in a 
10 percent ether solution. It is best to apply the 
chrysarobin at night, and to advise the patient to 
put on an old stocking, to prevent soiling the bed- 
clothing. Application once a day in this way 
seems ordinarily to be sufficient, but in obstinate 
cases it should be applied both night and morning. 
The influence of chrysarobin is not only upon 
the keratinized portion of the skin, but also upon 
the proliferated blood-vessels in the papillary 
central part, for both disappear and true skin is 
formed over the surface. 
WASSERMANN REACTION.-See Syphilis. 
WATER (Aqua). H2O.-Natural water in its 
purest attainable state is a colorless, limpid liquid, 
devoid of odor or taste, and neutral in reaction. 
Besides entering into the composition of most of 
the official extracts, fluidextracts, and many 
other pharamaceutic preparations, from it are 
prepared the official waters Aquas (see Aqua), and 
also the following: Aqua Destillata (distilled 
water), H20:1000 parts of water are distilled, the 
first 100 parts obtained being thrown away and 
800 parts preserved. It is as near chemically pure 
water as can be obtained. 
Uses of Water in the Human Body.-Water con- 
stitutes between 60 and 66 percent of the human WATER, EXAMINATION 
WATER, EXAMINATION 
body. Its uses have been well summarized by 
W. G. Thompson as follows: " (1) It enters into 
the chemical composition of the tissues. (2) It 
forms the chief ingredient of all the fluids of the 
body and maintains their proper degree of dilution. 
(3) By moistening various surfaces of the body, 
such as the mucous and the serous membranes, it 
prevents friction and the uncomfortable symptoms 
which might result from their drying. (4) It 
furnishes in the blood and lymph a fluid medium 
by which food may be taken to remote parts of the 
body and the waste matter removed, thus promot- 
ing rapid tissue changes. (5) It serves as a dis- 
tributor of body heat. (6) It regulates the body 
temperature by the physical processes of absorp- 
tion and evaporation." 
Nomenclature of Water.-See Aqua. 
Therapeutics.-Cold water or ice has many ex- 
ternal applications of value in the treatment of 
disease. As a wet pack it is used in tonsillitis, 
diphtheria, and croup. Cold baths are the most 
effective antipyretic in the high temperature of 
fevers, and the cold wet pack is used for the same 
purpose. Ice or cold water is applied to the head 
in acute cerebral congestion, and to the spine in 
chorea, etc.; also locally in hemorrhoids, bubo, 
orchitis, and to the uterus in postpartum hemor- 
rhage. Cold effusion to the body is employed as a 
preventive of spasmodic croup, as well as to lessen 
the tendency to taking cold. See Bath. 
Hot water externally-as fomentations, hot wet 
pack, hot baths, etc.-is most effective in reducing 
local congestion and in setting up resolution of 
local inflammation. Hot fomentations to the 
renal region are useful in functional inactivity of 
the kidneys. The hot spinal douche is used in 
affections of the spinal cord and meninges, and in 
the backache of women. The hot wet pack is 
highly esteemed in inflammation of the chest 
organs, and hot injections are useful in chronic 
inflammation of the uterus. Hot-water dressings 
for wounds are strongly favored by many sur- 
geons. Vapor and Turkish baths are used as 
diaphoretics in advanced kidney-disease, in acute 
and chronic rheumatism, in mineral poisoning, 
and in syphilis. Warm baths, with cold applica- 
tions to the head, are of value in infantile con- 
vulsions and chorea. See Bath. 
Internally, water is chiefly of value as a diuretic, 
and, if hot, as a diaphoretic. A glass of cold water 
before breakfast daily is often an effective means 
of overcoming constipation, while the drinking of 
hot water an hour before each meal has been of 
great benefit to many dyspeptics. The value of 
the popular teas in chronic diseases is almost 
entirely due to the diluent, diuretic, and diaphor- 
etic actions of the hot water used. 
In moderate quantity water is necessary to 
digestion, but large amounts weaken digestion by 
diluting the gastric juice. Ice-cold water, if 
freely used, suspends the action of pepsin and 
depresses the nerves of the stomach and lowers its 
blood supply. In some subjects the free use of 
water internally favors the deposition of fat. 
WATER, EXAMINATION.-A potable water is 
one that is apparently fit to drink. 
An unpotable water is one that is obviously 
unfit to drink. 
Characteristics of a good drinking water are: 
(1) It should be clear and limpid. Cloudy and 
muddy waters should be avoided. (2) It should 
be colorless. A greenish or yellowish color is 
usually due to vegetable or animal matter in 
solution or to organisms. (3) It should be odor- 
less; especially free from sulphuretted hydrogen or 
putrefactive animal matter. (4) It should not 
be too cold, but should have a temperature of 
from 46° F. to 60° F. (5) It should have an 
agreeable taste; neither flat, salty, nor sweetish. 
A certain amount of hardness and dissolved gases 
gives a sparkling taste. It should contain from 
25 to 50 c.c. of gases per liter, of which 8 to 10 per- 
cent is carbon dioxid and the rest oxygen and 
nitrogen. (6) It should be as free as possible 
from dissolved organic matter, especially of ani- 
mal origin. (7) It should not contain too great 
an amount of hardness. A certain quantity of 
saline matter is necessary, however, to give it a 
good taste. It should not contain over three or 
four parts of chlorin in 100,000 parts of water 
(Bartley). 
Diseases Which may be Transmitted by Drinking 
Water.-Typhoid, cholera, dysentery, diarrhea, 
indigestion, goiter, vesical calculi, intestinal 
worms, lead poisoning. 
At the present day the subject of drinking-water 
involves the interest, attention, and welfare of 
every civilized community. The question of 
health largely depends upon the water consumed, 
in which may reside the microorganisms of disease 
and death. In chemic examination the determi- 
nation of chlorids, of nitrites, and of free and 
albuminoid ammonia gives an index as to con- 
tamination, yet the proof is not absolute. 
When, however, an attempt is made to isolate 
the causative factors in such diseases as typhoid 
fever, cholera, etc., insurmountable difficulties may 
present themselves, from the fact that a few micro- 
organisms are scattered throughout a large volume 
of water, and that the portion of water selected 
for examination may yield negative results. This 
condition was instanced in Philadelphia during an 
epidemic of typhoid fever the origin of which was 
traced to a burst sewer-pipe that discharged its 
contents into the water-supply of a certain reser- 
voir. The disease was wide-spread among those 
who consumed this water, whereas persons in other 
sections of the city remained comparatively free. 
A thorough bacteriologic examination of the water 
failed to show the presence of the typhoid bacillus. 
Again, all varieties of potable water contain 
bacteria, most of which do not seem to be detri- 
mental to health, while water which may contain a 
few pathogenic bacteria gives rise to epidemic 
diseases. It is important, therefore, to determine 
a "standard" in this respect. After the definite 
number of colonies have been found in a given 
quantity of water, a sudden fluctuation of this 
number may indicate contamination. 
Qualitative Bacteriologic Analysis of Water.-By 
this is meant the isolation and study of different 
species of bacteria in drinking-water. WATER, EXAMINATION 
WATER, EXAMINATION 
In collecting the sample extreme care should 
be exercised to avoid its contamination. If water 
is to be collected from a hydrant or spigot, it 
should be allowed to run for from 15 to 20 minutes; 
if from a spring or lake, it should be taken from 
about a foot beneath the surface. The specimen 
should be examined near the region where the 
sample is procured, and as soon as possible after 
its collection. 
Abbott states that: " In the qualitative analysis 
it is necessary that a small portion of water-one, 
two, three, five drops-should first be employed, 
from which plates are to be made in order to 
determine the approximate number of organisms; 
also the amount of water necessary to use for each 
set of plates. Duplicate plates are always to be 
made-one set upon agar-agar, which should be 
kept in the incubator at the temperature of the 
body, and one set upon gelatin, to be kept at 
from 18° to 20° C." As soon as the colonies have 
developed, the plates are to be carefully studied 
and the results compared with subsequent inocula- 
tions into animals. 
Quantitative Estimation of Bacteria in Water.- 
The results of the quantitative estimation of 
bacteria in water are expressed in terms of the 
number of individual organisms to a definite 
volume. The water should be examined in the 
spot where it is collected. 
Collection of the Water.-For this purpose a 
glass bulb drawn out into a pointed extremity and 
sealed while hot should be used. The stem should 
be broken off under water, when, owing to negative 
pressure, the bulb fills with water. 
The number of organisms in a fixed volume is 
approximately determined by the plate or tube 
method, at first selecting 1 or 2 drops, and finally 
1 c.c. of water. If the original drop of water con- 
tained too many colonies to be counted, it should 
be diluted with 10, 25, or 100 volumes of water, the 
results being expressed in terms of the number of 
bacteria to a cubic centimeter of water. 
It is always essential to make duplicate plates. 
Method of Counting the Colonies on Plates.- 
For this purpose the Wolffhiigel's counting appa- 
ratus is used. When the colonies are quite small, 
an ordinary hand lens may be used. Esmarch also 
has devised an apparatus for counting the number 
of colonies of bacteria in water. 
Chemic Analysis of Water.-In order to deter- 
mine the fitness of a water for potable purposes both 
chemic and bacteriologic examinations are neces- 
sary. While the value of drinking-water may be 
judged by the chemic method alone, the evidence 
is not absolutely conclusive, because it is desired 
most frequently to determine whether or not there 
is pollution from sewage, and this information can- 
not always be derived from a chemic examination. 
Unfortunately, the bacteriologic examination does 
not always tell this, because it is hard to obtain a 
standard of water in which a certain number of 
colonies of bacteria can be allowed to a cubic centi- 
meter; and also on account of the fact that the 
typhoid bacillus or other pathogenic organism is 
seldom found, because so few bacteria exist in 
comparatively large quantities of water, and 
thus erroneous results may be derived from the 
examination. 
A method of analysis, though seemingly primi- 
tive, may and does frequently present such evi- 
dence as to prevent the use of contaminated water; 
this method may be called "examination by the 
senses," and, according to Blyth, "water that is 
evidently turbid, that possesses an odor and an 
unpleasant taste, requires no analytic processes 
to condemn it entirely; such water is unsuitable 
for drinking purposes." 
Another simple water test is as follows: Into a 
stoppered, ground-glass, perfectly clean bottle put 
5 ounces of the water to be tested. To the water 
add 10 grains of pure, granulated, white sugar. 
Cork tightly, and set in a window exposed freely 
to light, but not to the direct rays of the sun. Do 
not disturb the bottle, and keep the temperature 
as near 70° F. as possible. If the water contains 
organic matter, within 48 hours an abundance of 
whitish specks will be seen floating about; and the 
more organic matter, the more specks. In a week 
or 10 days, if the water is very bad, the odor of 
rancid butter will be noticed on removing the 
stopper. The little specks will settle to the bot- 
tom, where they appear as white, flocculent 
masses. Such water should not be used for 
potable purposes. 
Drinking-water should be free from such ele- 
ments as lead, copper, barium, zinc, manganese, 
chromium, and arsenic. After eliminating these 
elements, the chemic analysis of drinking-water 
resolves itself into the estimation of (1) the total 
amount of solids; (2) amount of chlorids; (3) 
amount of free and albuminoid ammonia; (4) 
amount of nitrates; (5) presence or absence of 
nitrites; (6) amount of hardness; (7) organic 
matter. 
Percentage of Elements Allowed in Potable Water. 
Total solids, 30 parts to 100,000 
Chlorids (NaCl), 2 or 3 parts to 100,000 (suspicious). 
Free and albuminoid 
ammonia, 0.15 parts to 1,000,000 
Nitrates, . 3 or 4 parts to 1,000,000 
Nitrites, none 
Hardness (CaCOs), 20 grains to 100,000 
Organic matter, 
The total solids are determined by evaporating a 
given quantity of water and weighing the residue. 
The chlorids are usually estimated as NaCl, and 
are determined by a standard solution (not a 
normal solution) of nitrate of silver. In this way 
the molecular weight of AgNO3 is expressed in 
milligrams (170 being the molecular weight of 
AgNO3 when dissolved in 1000 c.c.): 
1000 c.c. equals 170.0 grams 
100 c.c. equals 1.70 grams 
1 c.c. equals 0.0170 grams. (170 milligrams) 
Free and Albuminoid Ammonia.-For the esti- 
mation of free and albuminoid ammonia the most 
delicate apparatus must be used and exceedingly 
careful methods must be exercised. The requisites 
are (1) Nessler's solution; (2) solution of ammon- 
ium sulphate; (3) solution of sodium carbonate; 
(4) solution of potassium permanganate; (5) dis- 
tilled water free from ammonia. WATER, EXAMINATION 
WEIGHTS AND MEASURES 
Nessler's solution is prepared by dissolving 50 
grains of potassium iodid in a small quantity of 
hot water and adding, while the solution is hot, 
a strong aqueous solution of mercuric chlorid 
(40 grams to 300 c.c. of water) until the red precip- 
itate just redissolves; filter, add to the filtrate a 
strong solution of 200 grams of potassium hydrate, 
filter, dilute to 1000 c.c., add 5 c.c. of a saturated 
solution of mercuric chlorid, allow the precipitate 
formed to settle, decant the clear fluid, and pre- 
serve it in a glass-stoppered vial. 
To determine the amount of free ammonia, the 
water to be examined is placed in a retort with a 
small quantity of solution of sodium carbonate 
and distilled. The amount is determined by the 
Nessler solution, and a known quantity of ammon- 
ium sulphate is used as an indicator. 
To determine the amount of combined or albu- 
minoid ammonia, the distillate is freed from 
ammonia, potassium permanganate is added, and 
successive portions are tested until less than 0.01 
milligram of NH3 is obtained, deduct ammonia 
due to potassium permanganate and the result 
gives albuminoid (free) ammonia. 
The nitrates are determined by evaporating 2 
of 3 liters of water, adding caustic lime, heating, 
transferring to a Liebig condenser, and introducing 
a thin sheet of zinc plated with copper. The 
distillate is then evaporated with platinum tetra- 
chlorid and the amount of nitrates is calculated 
from the spongy platinum in terms of nitric acid. 
Nitrites.-The following method is sometimes 
used. It consists in placing the water to be 
tested in a narrow glass cylinder and adding 1 c.c. 
of a solution of sulphuric acid (35 percent), and 
afterward a solution of metaphenylenediamin, 
with a solution of argentic nitrate of known 
strength as an indicator, similar comparisons are 
made with the metaphenylenediamin until the two 
colors are identical, when the amount of nitrites in 
the given sample can be calculated. 
Hardness is mainly due to the bicarbonates of 
calcium and magnesium. To determine the 
hardness of water a solution of soap is made by 
dissolving 10 grams of soda soap in 1 liter of 90 
percent alcohol; filter this and add 100 c.c. of the 
filtrate to 100 c.c. of distilled water and 33 c.c. of 
alcohol. Then prepare a solution of calcium chlo- 
rid by adding a small quantity of dilute hydro- 
chloric acid to calcium carbonate, dissolving the 
residue in 1000 c.c. of water; dilute 10 c.c. of this 
with 100 c.c. of water, and add soda soap, shaking 
gently until a lather forms that remains unbroken 
for 5 minutes. From this as an indicator the 
amount of hardness is determined in a given 
sample of water. 
Organic Matter.-Evaporate 250 c.c. of water to 
dryness in a platinum dish, first in a water-bath, 
then in an air-bath, and reweigh. Heat again to 
a low red heat until all the organic matter is de- 
stroyed, add water saturated with CO2, evaporate, 
dry, and weigh. Repeat the process with CO2. 
The difference between this weight and the first 
expresses the amount of organic and volatile 
matter. Organic matter of animal origin-such 
as sewage-during oxidation first changes into 
nitrous acid and nitrites, then into nitric acid and 
nitrates. The presence of nitrites is always a 
cause for suspicion. Any increased amount of 
nitrates should be carefully watched. The pres- 
ence of nitrites, with an unduly large proportion of 
chlorid and of free and albuminoid ammonia, 
indicates the presence of sewage. In fresh sewage 
nitrites and nitrates may be diminished or absent. 
WEANING.-See Infant (Care), Milk 
(Mother's). 
WEBBED FINGERS (Syndactylism) .-This con- 
dition is treated by incising the web in such a way 
as to form a flap which is used to cover the raw 
Operation for Webbed Fingers.-{Stimson.) 
surface between the roots of the fingers, or by 
raising two flaps of skin by an incision along the 
middle of the palmar surface of one finger, and 
another along the dorsal surface of the other 
finger; the flaps are then separated and wrapped 
around the fingers. 
WEIGHTS AND MEASURES. 
Troy Weight. 
Grains. 
24 = 1 dwt. 
480= 20 dwt.= 1 oz. 
5760 = 240 dwt. = 12 oz. = l lb. = 22.816 cu. in. of distilled 
water at 62° F. 
Avoirdupois Weight. 
Drams. Ounces. 
16 = 1 = 437.5 grains troy. 
256= 16= 1 lb. = 1.2153 lb. troy. 
6400= 400= 25 lb. = 1 quarter. 
25,600= 1,600= 100 lb.= 4 quarters = 1 cwt. 
512,000 = 32,000 = 2000 lb. = 80 quarters = 20 cwt. = l ton. 
Grains. 
20= 1 scruple. 
60= 3 scruples = 1 dram. 
480= 24 scruples = 8 drams = 1 oz. 
5760 = 288 scruples = 96 drams = 12 oz. = l lb. 
Apothecaries' Weight. 
60 minims = 1 fluidram. 
8 fluidrams = 1 fluidounce. 
16 fluidounces =1 pint. 
2 pints = 1 quart. 
4 quarts = 1 gallon. 
Apothecaries' Measure. 
Forty-five drops of water, or a common tablespoonful, make 
about 1 fluidram; 2 tablespoonfuls, about 1 fluidounce; a wine 
glassful is about 11/2 fluidounces; and a teacupful, about 4 
fluidounces. WEIGHTS AND MEASURES 
WEIGHTS AND 
GUIs. 
1 =7.2187 cu. in. 
4= 1 pint 28.875 cu. in. 
8= 2 pints = 1 quart =55.75 cu. in. 
32= 8 pints = 4 quarts = 1 gallon. 
2016= 504 pints = 252 quarts = 63 gallons = 1 hogshead. 
4032 = 1008 pints = 504 quarts = 126 gallons = 2 hogsheads = 1 pipe. 
8064 = 2016 pints =1008 quarts = 252 gallons = 4 hogsheads =2 pipes = 1 tun. 
Liquid or Wine Measure. 
Long Measure. 
Inches. 
12 = 1 foot. 
36= 3 feet= 1 yard. 
72= 6 feet= 2 yards = 1 fathom. 
198= 16.5 feet = 5.5 yards = 2.75 fathoms = 1 perch. 
7920= 660 feet= 220 yards = 110 fathoms = 40 perches = 1 furlong. 
63,360 = 5280 feet = 1760 yards = 880 fathoms = 320 perches = 8 furlongs = 1 mile 
Sq. Inches. Sq. Feet. 
144= 1 
1296= 9 =1 sq. yard. 
39,204= 272.25= 30.25 sq. yards = 1 perch. 
1,568,160=10,890 =1210 sq. yards = 40 perches = 1 rood. 
6,272,640 = 43,560 =4840 sq. yards = 160 perches = 4 roods = 1 acre. 
An acre is 69.5701 square yards; or, 208.710321 square feet. 
Square Measure. 
A township is 6 miles square = 36 sections. 
A section is 1 mile square = 640 acres. 
i section is J mile square = 160 acres, 
section is 1 mile square = 40 acres. 
The standard United 
States bushel is the 
Winchester bushel (cyl- 
inder form, 18J in. diam- 
eter, and 8 in. deep). 
= 2150.42 cubic inches. 
The English Imperial bushel = 
2218.192 cubic inches. 
1.03152 U. S. bushels. 
The English quarter = 
8 Imperial bushels. 
8i (nearly) U. S. bushels. 
10.2694 cubic feet. 
Solid Measure. 
Cu. In. 
1728= 1 cubic foot. 
46,656 = 27 cubic feet=l cubic yard. 
Metric or French Weights. 
Gram. 
Troy Grains. 
Milligram 
= 0.001 = 0.01543 
Centigram 
= 0.01 = 0.15433 
Avoir 
Avoir 
Decigram 
= 0.1 
= 1.5433 
Ounces. 
Pounds. 
Gram 
= 1 
= 15.43316 = 
0.03528 = 
0.0022047 
Decagram 
= 10 
= 
0.3528 = 
0.022047 
Hectogram 
= 100 
= 
3.52758 = 
0.2204737 
Kilogram 
= 1000 
= 
35.2758 = 
2.204737 
Myriogram 
- 10,000 
=s 
22.04737 
Quintal 
= 100,000 
=s 
220.4737 
Tonneau 
= 1,000,000 
= 
2204 737 
Dry Measure. 
Pints. 
1 =33.6 cubic inches. 
2=1 quart =67.2 cubic in. 
8= 4 quarts = 1 gallon =268.8 cubic in. 
16= 8 quarts = 2 gallons =1 peck =537.6 cubic in. 
64 =32 quarts = 8 gallons = 4 pecks = 1 bushel. 
Metric or French Dry and Liquid Measures. 
Lit. U. S. Cu. In. 
Liquid 
0.00845 
U. S. 
gill. 
Milliliter 
= 
0.001= 0.061= { 
Dry 
0.0018 
pint. 
Centiliter 
Liquid 
0.0845 
gill- 
= 
0.01 = 0.61 = { 
Dry 
0.018 
pint. 
Deciliter 
Liquid 
0.845 
gill = 0.2113 pint 
= 
0.1 = 6.1 -{ 
Dry 
0.18 
pint. 
Liter 
1 = 61.02 = { 
Liquid 
2.113 
pints = 1.057 quarts. 
= 
Dry . 
1.8 
pints = 0.908 quart. 
Decaliter 
10 =610.16 = / 
Liquid 
2.641 
gallons. 
U. S. Cu. Ft. 1 
Dry 
9.08 
quarts = 1.135 pints. 
Hectoliter 
= 
100 = 3.531=| 
Liquid 
Dry 
26.414 
2.837 
gallons, 
bushels. 
Kiloliter 
1000 = 35.31 = | 
Liquid 
Dry 
264.141 
28.374 
gallons, 
bushels. 
Myrialiter 
- 
10,000 =353.1 =| 
Liquid 2641.4 
Dry 283.7 
gallons, 
bushels. 
Metric or French Linear Measure. 
Meter. U. S. In 
Ft. 
Millimeter1 
= 
0.001= 0.03937 
=8= 
0.00328 
Centimeter2 
=8 
0.01 = 0.3937 
= 
0.03280 
Yd. 
Decimeter 
= 
0.1 = 3.937 
= 
0.32807 
= 
0.10936 
Meter 
888 
1 =39.3685 
= 
3.2807 
8= 
1.0936 
Decameter 
= 
10 
=88 
32.807 
= 
10.936 
Mile. 
Hectometer 
= 
100 
= 
328.07 
= 
109.36 
= 0.0621347 
Kilometer 
= 
1000 
= 
3280.7 
= 
1093.6 
= 0.6213466 
Myriameter 
= 
10,000 
= 
32,807 
= 
10,936 
= 0.213466 
'Nearly as of an inch. 
2Full i of an inch. WEIGHTS AND MEASURES 
WEIGHTS AND MEASURES 
Sq. Meter. U. S. Sq. In. 
Sq. centimeter 
Sq. decimeter 
= .0001= 0.155= Sq. Ft. Sq. Yd. 
= .01 = 15.5 = 0.10763= 0.01196 
Acre. 
Centiare 
= 1. = 1549.88 = 10.763 = 1.196 = 
0.00025 
Are 
= 100. = 154988 = 1076.3 = 119.6 
0.0247 
Hectare 
= 10,000. = 107,630 = 11,959 = 
2.47 
Sq. kilometer 
= 0.38607 sq. mile. = 
247 
Sq. myriameter 
= 38.607 sq miles. = 
24,708 
Metric or French Square Measure. 
COMPARISON OF U. S. FOREIGN WEIGHTS AND MEASURES. 
Weights. 
Liquid Measures. 
Dry Measures. 
Name. 
U. S. lb. Av. 
Name. 
U 
S. gal. 
Name. 
U. S. bush. 
Austria, 
Pfund 
= 1.235 
Euner 
= 
14.95 
Nutze 
= 1.745 
Bremen, 
Pfund 
= 1.099 
Stubchen 
= 
0.851 
Scheffel 
- 2.103 
Buenos Ayres, 
Libra 
= 1.0127 
Frasco 
- 
0.627 
Fanega 
- 3.894 
China, 
Catty 
= 1.3333 
Sei 
- 3.472 
Cuba, 
Libra 
= 1.0119 
Arroba 
- 
4.1 
Fanega 
= 3.124 
Denmark, 
Pund 
=1.1025 
Pott 
- 
0.255 
Fonda 
= 3.948 
England, 
Pound 
= 1 
Imp. gallon 
- 
1.2003 
Imp. bu. 
- 1.0315 
France, 
Kilo 
= 2.0246 
Liter 
- 
0.2642 
Hectoliter 
= 2.838 
Hamburg, 
Pfund 
= 1.0683 
Ohm 
38.278 
Fass 
- 1.56 
Japan, 
Monme 
= 3.858 
Masa 
- 
0.459 
Mexico, . 
Libra 
= 1.0119 
Frasco 
- 
0.4 
Fanega 
- 1.547 
Norway and Sweden, ... 
Skalpund 
= 0.937 
Kamea 
- 
0.662 
Papal States 
Libbra 
= 0.7475 
Barile (w'e) 
= 
15.412 
Rubblio 
= 0.836 
Portugal, 
Libra 
= 1.0119 
Almude 
= 
4.422 
Alqueire 
= 0.393 
Russia 
Funt 
= 0.907 
Vedro 
= 
3.249 
Chetviert 
= 5.956 
Turkey, 
Oke 
= 2.834 
• 
Kilo 
= 1.001 
TABLE FOR CONVERTING METRIC WEIGHTS INTO TROY WEIGHTS 
0.1 
0.2 
0.3 
0.4 
0.5 
0.6 
0.7 
0.8 
0.9 
1.0 
2.0 
0.01 
0.02 
0.03 
0.04 
0.05 
0.06 
0.07 
0.08 
0.09 
Grams. 
1.543 
3.086 
4.630 
6.173 
7.716 
9.259 
10.803 
12.346 
13.889 
15.432 
30.865 
0.1543 
0.3086 
0.4630 
0.6173 
0.7717 
0.9260 
1.0803 
1.2347 
1.3890 
Exact Equiva 
LENTS IN 
Grains. 
- 
Ounces. 
> 
• • • • • • • • • • • • • • • • • • • • 
Drams. 
o 2 
*4 < 
to 
O 
3 
2 
► 
Scruples. 
E § 
2 h 
13 
3 
43 
6i 
7} 
9i 
101 
123 
14 
15| 
10$ 
fl 
11 
I 
II 
V 
I 
1 
Grains. 
M 
3.0 
4.0 
5.0 
6.0 
7.0 
8.0 
9.0 
10.0 
11.0 
12.0 
13.0 
14.0 
15.0 
16.0 
17.0 
18.0 
19.0 
20.0 
21.0 
22.0 
Grams. 
185.188 
200.621 
216.053 
231.485 
246.918 
262.350 
277.782 
293.215 
308.647 
324.079 
339.512 
46.297 
61.729 
77.162 
92.594 
108.026 
123.459 
138.891 
154.323 
169.756 
Exact Equiva- 
lents in 
Grains. 
::::::::::: 
Ounces. 
tOtOtOtOH-F-t-*^^ 
Drams. 
o 2 
»4 < 
> 
ha 
E § 
2 h 
0 
a 
E 
► 
H H : tO h- • to H H 
to h • • to H .* to 
Scruples. 
5$ 
3 
5 
16 
113 
6 A 
23 
17$ 
13$ 
83 
4i\, 
193 
16 
V8I 
fs 
8 
1ST 
fzi 
31 
19 
Grains. 
M a 
® g 
M 
32.0 
40.0 
45.0 
50.0 
60.0 
70.0 
80.0 
90.0 
100.0 
23.0 
24.0 
25.0 
26.0 
27.0 
28.0 
29.0 
30.0 
31.0 
Grams 
493.835 
617.294 
694.456 
771.617 
925.941 
1080.264 
1234.588 
1388.911 
1543.235 
354.944 
370.376 
385.809 
401.241 
416.673 
432.106 
447.538 
462.970 
478.403 
Exact Equiva 
LENTS IN 
Grains. 
- 
WtOUWHHHHH 
Ounces. 
Equivalj 
Troy W 
t-»<I^tO<I^WtO* 
Drams. 
hi 
to 
o 
X 
to ■ »-* • H tO M • 
to to H* . to to h* • to 
Scruples. 
H £ 
5 H 
2 
► 
13$ 
17™ 
103 
Ils 
6 
t 
14$ 
9 
3i 
5 
10$ 
5$ 
It 
16$ 
12i« 
73 
3 
183 
Grains. 
M WEIGHTS AND MEASURES 
WEIGHTS AND MEASURES 
Centi- 
meters. 
Inches. 
ONE BEER QUART 
146.910111 in height. 
ONE LITER 
Circular base 100 millimeteters in diameter. WEIL'S DISEASE 
WHOOPING COUGH 
TABLE FOR CONVERTING TROY WEIGHTS INTO METRIC WEIGHTS 
Grains. 
0.0648 
0.1296 
0.1944 
0.2592 
0.3240 
0.3888 
0.4536 
0.5184 
0.5832 
0.6480 
0.7130 
0.7776 
0.8424 
0.9072 
0.972 
Grams. 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
29 
30 
Grains. 
1.037 
1.102 
1.166 
1.231 
1.296 
1.361 
1.426 
1.490 
1.555 
1.620 
1.685 
1.749 
1.814 
1.869 
1.944 
Grams. 
31 
32 
33 
34 
35 
36 
37 
38 
39 
40 
41 
42 
43 
44 
45 
Grains. 
2.009 
2.073 
2.138 
2.203 
2.268 
2.332 
2.397 
2.462 
2.527 
2.592 
2.656 
2.721 
2.786 
2.851 
2.916 
Grams. 
46 
47 
48 
49 
50 
51 
52 
53 
54 
55 
56 
57 
58 
59 
60 
Grains. 
2.980 
3.045 
3.110 
3.175 
3.234 
3.304 
3.369 
3.434 
3.499 
3.564 
3.628 
3.693 
3.758 
3.823 
3.888 
Grams. 
61 
62 
63 
64 
65 
66 
67 
68 
69 
70 
71 
72 
73 
74 
75 
Grains. 
3.952 
4.017 
4.082 
4.147 
4.211 
4.276 
4.341 
4.406 
4.471 
4.535 
4.600 
4.665 
4.730 
4.795 
4.859 
Grams. 
76 
77 
78 
79 
80 
81 
82 
83 
84 
85 
86 
87 
88 
89 
90 
Grains. 
4.924 
4.989 
5.054 
5.118 
5.183 
5.248 
5.313 
5.378 
5.442 
5.507 
5.572 
5.637 
5.702 
5.766 
5.831 
Grams. 
91 
92 
93 
94 
95 
96 
97 
98 
99 
100 
120 
150 
180 
200 
240 
Grains. 
5.896 
5.961 
6.026 
6.090 
6.155 
6.220 
6.285 
6.350 
6.414 
6.479 
7.776 
9.719 
11.664 
12.958 
15.552 
Grams. 
OOOOOOOCCOOO 
ooooooooooo 
Grains. 
19.440 
23.328 
25.920 
31.103 
32.396 
38.875 
45.354 
51.833 
58.313 
62.207 
64.792 
Grams. 
WEIL'S DISEASE (Acute Febrile Jaundice, 
Infectious Jaundice, Bilious Typhoid). Etiology.- 
Males, young or middle-aged, especially laborers, 
brewers and butchers, are the subjects as a rule. 
Exposure to cold may be an exciting cause. It is 
most common in the summer and occurs in groups 
of cases. Probably it is caused by more than 
one microorganism. 
Symptoms.-The onset is generally sudden, with 
a chill, followed by fever, headache, nausea, 
general pains and epigastric pain. Jaundice 
appears early. The liver •and spleen are enlarged 
and may be tender. The stools may be clay- 
colored. The urine is dark and contains bile 
pigment, sometimes albumin and casts and blood. 
Fever lasts from 8 to 14 days and is remittent in 
character. 
Diagnosis.-Bilious malarial fever may be 
excluded by the absence of piasmodia in the 
blood. The presence of fever, muscular, joint and 
epigastric pain distinguish it from catarrhal 
jaundice. Acute yellow atrophy of the liver and 
phosphorous poisoning are excluded by the mild 
course and favorable outcome. 
Prognosis is generally good. 
Treatment is symptomatic. 
WERNICKE'S SIGN (Hemiopic Pupillary Inac- 
tion).-If a bright light is thrown into the eye and 
the pupil reacts, the integrity of the reflex arc is 
demonstrated. It is possible, in cases of lateral 
hemianopsia, to throw the light into the eye so that 
if falls upon the blind half of the retina. If, 
when this is done, the pupil contracts, the indica- 
tion is that the reflex arc referred to is perfect, 
by which is meant that the optic nerve-fibers 
from the retinal expansion to the center, the 
center itself, and the third nerve are uninvolved. 
In such a case the conclusion would be justified 
that the cause of the hemianopsia was central; 
that is, situated behind the geniculate bodies, either 
in the fibers of the optic radiation or in the 
visual cortical centers. If, on the other hand, 
when the light is carefully thrown on the hemiopic 
half of the retina, the pupil remains inactive, the 
conclusions are justifiable that there is interrup- 
tion in the path between the retina and the gen- 
iculate bodies, and that the hemianopsia is not 
central, but is dependent upon a lesion situated 
in the tract. See Hemianopsia. 
WET PACK.-See Pack. 
WHEY.-The liquid part of milk separating 
from the curd in coagulation. Alum whey is sepa- 
rated by stirring milk with a lump of alum; a 
popular remedy for sore eyes. 
Wine whey is prepared by adding Rhine wine, 
1 part, to hot milk, 4 parts, and straining. See 
Infant Feeding. Whey cure, a cure for chronic 
catarrh of the respiratory organs. This consists 
in drinking warm whey, either alone or mixed 
with a mineral water, in definite quantities at set 
times. About 20 ounces are taken daily. This 
is regarded by many as in all respects similar 
to the use of skimmed milk. Sometimes the 
method is combined with baths of whey. 
WHISKY.-See Alcohol; Spirits. 
WHITE SWELLING.-See Joints (Diseases) 
(Tubercular Arthritis). 
WHITES.-See Leukorrhea. 
WHITLOW.-See Paronychia. 
WHOOPING-COUGH (Pertussis).-A highly 
contagious disease, characterized by inflamma- 
tion of the respiratory tract, associated with a 
peculiar spasmodic cough ending in a whooping 
inspiration. 
Etiology.-A bacillus described by Bordet and 
Gengou, similar to that of influenza, is the cause of 
whooping cough; this bacillus is discharged in the 
sputum and nasal secretions. This disease is di- 
rectly very contagious, next to measles probably 
the most so of any of the infectious diseases, and 
it is possible for it to be carried by a third person. 
One attack usually protects from a second. It is 
most likely to occur before the tenth year; and 
although infants are not so susceptible as older 
children, it frequently does occur at that period 
of life, and is then a fatal disease. 
Pathology.-There are no characteristic patho- 
logic lesions due to whooping-cough, but post- 
mortem there are found-besides the catarrhal 
condition, which is always present to some extent 
-lesions due to complications. 
Symptoms.-The period of incubation is from WHOOPING COUGH 
WHOOPING COUGH 
4 to 14 days, during which time there are no 
symptoms to indicate the onset of the disease. 
In the clinical course three stages are usually 
noticed: viz., the catarrhal stage, the paroxysmal 
stage, and the stage of decline. The first symp- 
toms are those of a slight bronchial catarrh, which 
is worse at night. The cough is of a laryngeal 
type, and has a peculiar ring. 
The child at this time has some fever, the appe- 
tite is poor, and the sleep is restless. The cough 
gradually increases, and after a few days is out 
of proportion to the physical signs, only a few 
dry rales being found on examining the chest, 
fhe physiognomy changes, the face becomes 
swollen, the eyes are suffused and the under lids 
are swollen and pink in color. This characteristic 
of the under lids may be recognized before the 
whoop appears, and is a valuable diagnostic sign. 
During the paroxysmal stage, which begins 
about the second week, the cough becomes 
spasmodic. The child often has a premonition 
of the onset of a spasm, and will run to its mother 
or nurse or grasp a chair in its efforts to be 
relieved. 
The paroxysm consists of a number of short, 
spasmodic expiratory coughs, succeeded by a long- 
drawn inspiration and the peculiar whoop. 
Drinking, eating, crying, or any excitement will 
often bring on an attack. There may be 3 or 4 
paroxysms in rapid succession, followed by a 
period of several hours when the child apparently 
feels as well as usual. 
The attacks of coughing are frequently followed 
by eructations of stringy mucus, which may be 
streaked with blood, and vomiting of mucus and 
of the food which has been eaten is quite common. 
Nose-bleed is not unusual during this stage, and 
there may be ecchymoses, giving the skin a livid 
appearance. Extravasation of blood under the 
conjunctiva may occur, and the pink color and 
swollen appearance of the lower lids are more 
characteristic than during the catarrhal stage. 
The physical signs of the chest are not character- 
istic. Between the attacks of coughing the child 
may play about and may seem as well as usual. 
The patients, however, as a rule, suffer more 
or less from malnutrition and weakness, and 
young infants frequently from gastrointestinal 
disturbances, which may prove a dangerous 
complication. 
The number of paroxysms vary; usually, one 
occurs about every hour, or there may be as many 
as 30 or 40 in the course of the 24 hours. In 
young children the whoop may be absent. This 
is also noticed when pneumonia occurs as a com- 
plication, but the whoop appears again as the 
lungs clear. Long after an attack of whooping- 
cough is over the paroxysms may occur again and 
again, being brought on by a slight cold or by 
catarrh of the respiratory tract. The paroxysmal 
stage continues for a period of 3 or 4 weeks or 
longer. 
The third stage, or stage of decline, begins when 
the cough grows less in intensity. The sputum 
is then not so tenacious, but becomes purulent. 
The cough is less violent, and occurs at less 
frequent intervals. This stage continues for 
2 or 3 weeks. 
Complications.-In infants convulsions are com- 
mon when the cough is most severe; they are apt 
to be general and severe, and often prove fatal. At 
times vomiting becomes a serious complication, 
and it may reduce the child's strength to such a 
point as to endanger life. Severe bronchitis and 
bronchopneumonia occur quite frequently, and 
are dangerous complications. Adenoids greatly 
increase the dangers. 
Diagnosis.-Until the whoop appears it is fre- 
quently impossible to make a diagnosis; but the 
troublesome cough, especially at night, and the 
absence of physical signs to account for it, with the 
peculiar puffy appearance of the face and the 
swollen and pink under eyelids, previously 
mentioned, are quite positive signs. A simple 
catarrhal laryngitis may sometimes simulate pertus- 
sis, but there is no distinct whoop, and the symp- 
toms do not progressively increase and continue 
for a long period, as in the latter disease. Vomit- 
ing at the end of a paroxysm is a most suspicious 
symptom of whooping-cough. 
Prognosis.-The older the child, the more favor- 
able the prognosis. As stated, pertussis in infants 
is a very serious affection, the mortality being 25 
percent in the first year. Children who are debil- 
itated and poorly cared for also suffer severely 
from this disease. If between the paroxysms the 
child is well, the prognosis is very favorable; but if 
fever, accelerated breathing, somnolence, and per- 
sistent intestinal catarrh are present, the outlook is 
unfavorable. As a rule, whooping-cough is not a 
fatal disease, but the tendency to complications 
and the appearance of sequels affecting the lungs 
make it necessary to watch every case with care. 
Treatment.-The child should be isolated during 
the whole course of the disease. The hygienic 
treatment of pertussis is very important, and all 
cases should receive careful treatment, as the 
attack may thus be shortened, and the danger of 
serious complications may be rendered much less. 
The patient should be surrounded constantly by 
fresh air, to accomplish which it is of advantage to 
have two rooms, airing one while the other is being 
occupied. The room should be kept at a uniform 
temperature of about 65° F., and the child should 
be protected from drafts while sleeping by placing 
mosquito netting over the bed or crib. On pleas- 
ant days that are not windy it is an advantage to 
keep the child in the open air as much as possible. 
Careful attention should be paid to feeding, 
especially in infants, whose nutrition is so easily 
interfered with. They should be nursed regularly 
if at the breast, and if fed by the bottle, should 
receive a properly modified milk diet. When 
vomiting follows a paroxysm of coughing and 
causes the food to be ejected, another feeding 
should be given at once. Small quantities at 
frequent intervals are more likely to be retained 
than the usual amount every 2 1/2 or 3 hours. 
In the treatment of this disease it is important 
that it be recognized early. 
During the catarrhal stage it is a local affection, 
and treatment locally at this time will in many WIDAL REACTION 
WORMS 
cases shorten the duration. For this purpose the 
following formula is valuable to sterilize the throat 
and nose: 
developed subsequent to the bottling, whereby 
quantities of carbon dioxid are developed and held 
dissolved under pressure. See Vinum. W., Bar- 
ley, beer. W.-blue, the coloring-matter of red 
wines, a blue substance similar to litmus, possess- 
ing the property of turning red in the presence of 
acids. W., Burgundy, a heavy red or white wine 
from Burgundy, France. W., High, commercial 
ethyl-alcohol. W., Low, the products of the first 
distillation. W., Maderia, a heavy wine from 
the island of Maderia, having a nutty flavor. W., 
Malaga, a sweet wine from Malaga, in Spain; it 
contains between 13 and 14 percent of alcohol. 
W., Milk, fermented milk. W., Moselle, a light wine 
from the valley of the Moselle, in Germany. W., 
Mulled, a preparation made by adding eggs and 
spices to wine and then heating it. W., Oil of. 
See W., Heavy Oil of. W., Heavy Oil of, ethereal 
oil. W., Light Oil of, etherol, a yellowish liquid of 
a peculiar odor obtained from ethereal oil. W., 
Port, a heavy wine from Oporto, Portugal. W., 
Raisin, wine consisting mainly of a fermented 
infusion of raisins; it contains also the fermented 
juice of fresh grapes, sugar, and tartaric acid. W., 
Red. See Vinum Rubrum. W., Sherry, a heavy 
wine from the region of Xeres, in Spain; it is white 
or brown in color. The sherry wine often marketed 
seldom contains any wine, but consists of alco- 
hol, water, and flavoring ingredients. W., Spirit 
of, ethyl-alcohol. W., Whey, a nutritious and 
slightly stimulating preparation used in adynamic 
states. It is made of white wine and milk, from 
2 to 8 ounces of the former being added to a pint 
of the latter at the boiling temperature; the whey 
is then strained off and sweetened. W., White. 
See Vinum Album. 
Heavy wines are wines containing more than 12 
percent by weight of alcohol. Light wines are 
wines containing less than 12 percent by weight of 
alcohol, as claret, Sauterne, or Moselle. 
WINGED SCAPULA.-See Sprengel's Shoulder. 
WINKING.-See Nictitation. 
WINTERGREEN.-See Gaultheria. 
WITCH-HAZEL.-See Hamamelis. 
WITNESSES, MEDICAL.-See Expert Testi- 
mony. 
WOLF'S-BANE.-See Aconite. 
WOMB.-See Uterus. 
WOOL-SORTER'S DISEASE.-See Anthrax. 
WORD-BLINDNESS.-See Aphasia 
WORMS.-The worms that are parasitic in man 
are the flat worms, and the round worms. 
Flat worms (plathelminthes) are subdivided into 
the fluke-worms (trematodes) and the tape-worms 
(cestodes). 
Fluke-worms (trematodes).-The chief worms of 
this order are: (1) The distomum hepaticum (liver 
fluke). See Distomiasis. (2) The distomum 
heterophyes (Egyptian intestinal fluke). (3) The 
Schistosomum hematobium (African blood fluke). 
(4) The schistosomum Japonicum (Asiatic blood 
fluke). See Schistosomiasis. 
Tape-worms or Cestodes. 
To this order belong (1) the taenia solium; 
(2) the taenia saginata; (3) the bothriocephalus 
R. Hydrogen dioxid, 
Glycerin, 
each, 3 ss 
Spray thoroughly through the nares every 4 
hours. 
When the cough is fully established and is 
accompanied by eructations of stringy mucus, 
mixture of asafetida, in 1/2 teaspoonful doses 
every 2 hours, should be given. Belladonna is a 
very useful remedy, and should be given in doses 
sufficient to cause flushing of the face. The tinc- 
ture of belladonna may be given every 3 or 4 
hours, in doses of one drop for each month of the 
child's age, gradually increasing the dose until 
toxic effects are produced. The dose of atropin 
may be more easily regulated, and it may be given 
instead of belladonna, giving from 1 to 5 drops of 
the following every 3 or 4 hours: 
R. Atropin sulphate, gr. j 
Water, 3 j. 
In young infants a belladonna plaster placed 
between the scapulae will often give good results. 
Antipyrin combined with belladonna seems to 
have a more favorable action than either drug 
alone: 
R. Anti pyrin, 5 j 
Tincture of belladonna, 5 iv 
Brandy, 3 iv 
Water, 3 uj. 
Give 1/2 to 1 teaspoonful every 4 hours to a 
child 3 or 4 years of age. 
Bromoform may be given to quiet the cough: 
R. Bromoform, gr. x 
Alcohol, 3 j 
Simple syrup, 3 iv 
Water, 3 ijss. 
To a child 2 or 3 years old give 1 teaspoonful 
every hour until quiet. 
Inhalations of quinin solution or of oxygen or of 
ethyl iodid are recommended. 
During convalescence, if the indications seem 
to demand tonics, cod-liver oil, syrup of iodid of 
iron, syrup of hydriodic acid, etc., should be given, 
and the child should be as much as possible in the 
open air, preferably at the seashore. 
Serum or vaccine therapy has proved valuable in 
the hands of several observers. 
WIDAL REACTION.-See Typhoid Fever. 
WILD CHERRY.-See Prunus Virginiana. 
WINE.-The fermented juice of various species 
of Vitis. A sweet wine is one in which a notable 
portion of the original grape-sugar of the must has 
escaped fermentation, or to which an addition of 
sugar has been made subsequent to the main 
fermentation. A dry wine is one in which the 
sugar, whether originally present or subsequently 
added, has almost all undergone change in the proc- 
esses of fermentation. A sparkling wine is one in 
which a supplementary fermentation is purposely 
Water, 3 iij- WORMS 
WORMS 
latus; (4) the taenia echinococcus, the larval stage 
of which forms the hydatid cyst. See Liver; 
Hydatid Cyst; (5) the taenia nana (dwarf tape- 
worm) of southern Europe. 
The taenia solium, the "armed tape-worm," is 
the most common in this country. It is derived 
from the embryos contained in pork, known as 
the cysticercus cellulosae. It is from 6 to 30 feet 
in length, and has a globular head, or scolex, and 
parasite and are discharged either alone or with 
the feces. 
The taenia saginata, the "unarmed tape-worm" 
-a not uncommon variety-is derived from the 
embryos contained in beef, 
known as cysticercus bovis. 
This worm is from 10 to 40 
feet in length, has a rounded 
or oval-shaped head that 
measures about 1/10 of an 
inch, and has 4 strong and 
prominent suckers, but no 
booklets-whence the term 
"unarmed tape-worm"; the 
neck is short and thick and 
the segments are larger, 
stronger, and thicker than 
those of the taenia solium. 
The bothriocephalus latus 
(fish tape-worm, taenia lata), 
also an " unarmed tape- 
worm," the largest parasite 
infesting man, is supposed 
to be derived from an em- 
bryo found in fish. The 
embryo, or ovum, is intro- 
duced into the intestinal 
canal with the food and 
drink. The parasite reaches 
its final growth after its en- 
trance into the intestines. 
Those handling fresh meats 
or those eating uncooked ani- 
mal food are most liable to be 
affected. Uncleanliness is also an important 
factor. This worm is larger than the taenia solium 
and the taenia saginata, the length ranging from 
15 to 60 feet; the head is oval, measuring about 
1/10 inch; the neck is short, and the segments or 
joints are nearly three times as broad as they are 
long. Its color is a dull, bluish-gray. Zoologic- 
ally considered, this variety is not a true tape- 
wmrm. 
a slender neck, connecting its numerous flat seg- 
ments or joints. The head, or scolex, measures 
about 1/40 inch, has a double circle of booklets- 
whence the term "armed tape-worm"-and is pro- 
vided with from 2 to 4 suckers. The segments or 
joints (strobila) are flat, and 
vary from 1/8 to 1/2 of an 
inch in length. Each seg- 
ment contains both male 
and female sexual organs, 
the uterus being a long, 
numerously branched tube, 
in which the ova develop. 
The ovum measures about 
Head and Egg of T.unia Solium. 
Bothriocephalus 
Latus.-{Leuckart.) 
T^nia Saginata. 
Cephalic End of T^nia 
Sagin ata; A. Retracted 
head. B. Extended head. 
Ova of Bothriocephalus Latus. 
A, after treatment with sulphuric acid so as to render 
lid apparent; B, natural appearance in fecal matter. 
Symptoms.-Not infrequently a taenia produces 
no symptoms whatever. Usually, however, there 
are colicky pains throughout the abdomen, inordi- 
nate appetite, disorders of digestion, emaciation, 
constipation, attacks of cardiac palpitation, faint- 
ness, disorders of the special senses, and pruritus of 
the anus and nose. Any or all of these symptoms 
may be present. A large meal will often remove 
1/1700 inch in diameter. An ordinary tape- 
worm contains some 5,000,000 ova. The parasite 
is firmly embedded in the mucous membrane of 
the upper third of the small intestines by its hook- 
lets and suckers. The lower or terminal segments 
represent the adult and complete animal, and are 
termed the proglottides; these separate from the WORMS 
the majority of the symptoms. In a great many 
cases the discovery of the segments is the first 
intimation of the presence of the parasite. 
Treatment.-Many remedies have been sug- 
gested for the tape-worm. Pomegranate, pepo, 
male-fern, creosote, glycerin (2 drams to 1 ounce), 
pelletierin tannate (10 to 20 grains), have all been 
used. The following is often successful: 
WORMS 
some 60,000,000 in a mature female-and have 
wonderful vitality, resisting extreme heat or cold. 
Round-worms inhabit principally the small intes- 
tines, although they often migrate to other parts. 
From one to several hundred worms may be found. 
Symptoms.-The ascaris lumbricoides may be 
present in great numbers and yet produce no 
characteristic symptoms other than those of gas- 
tric and intestinal irri- 
tation such as pick- 
ing the nose, foul 
breath, colicky pains, 
nausea and vomiting, 
diarrhea, and disturb- 
ed sleep - tossing 
from side to side of the 
bed and grinding the 
teeth. Any or all of 
these symptoms may 
be present or absent; 
a positive diagnosis 
may be based upon the 
passage of the para- 
site, which is often the 
first thing to call atten- 
tion to the condition. 
The presence of 1 or 
2 round-worms- may 
cause no symptoms 
per se. Round-worms 
have been discharged 
from abscesses in the 
abdominal wall, and 
have obstructed the 
bile-duct and found 
their way into the per- 
itoneal cavity. 
Treatment.-The fluidextract of spigelia, the 
fluidextracts of spigelia and senna combined, the 
oil of chenopodium, the infusion of brayera or 
kousso, and santonin are the drugs usually em- 
ployed against the ascaris. One dram of spigelia 
and from 2 to 3 drams of spigelia and senna, in 
divided doses, may be given to a child of 3 years. 
From 5 to 20 drops of the oil of chenopodium may 
be given on lumps of sugar. 
I). Chloroform, 
Fluidextract of male-fern, 
each, 5 j 
To be taken in the early morning with no food 
to follow until there has been thorough 
action of the bowels. 
Emulsion of castor oil, 5 iij. 
Another successful plan is to boil pomegranate 
seeds (2 ounces) in 1 pint of water down to 7 
ounces; add pumpkin seeds (1 ounce), deprived of 
their outer coats and beaten to a paste with finely 
powdered sugar; to this add oleoresin of male-fern 
(30 grains) made into an emulsion -with acacia, 
and flavored with syrup enough to make 9 ounces. 
One-third of this mixture is to be taken after a 
light diet in the morning, a laxative having pre- 
ceded it the previous day. A second and a third 
portion are to be taken at intervals of 3 hours, if 
not previously successful. The worm should be 
passed while sitting in a warm sitz-bath, in order 
that the weight of the expelled portion may not 
break off before the expulsion of the head. It is im- 
portant to remove the head. See Anthelmintics. 
Round-worms or Nematodes. 
1. Angiostomidse to which species belong the 
tropical strongyloides intestinalis. This worm has 
been encountered in the Southern States. The 
presence of large numbers of this species may in- 
duce enteritis and anemia. They may be expelled 
by ethereal extract of male fern. 
2. Filariidse. See Filariasis, Guinea-worm 
Disease. 
3. Trichotrachelidse, which includes the trichi- 
uris trichiura (trichocephalus dispar, whip-worm) 
one of the most common and least harmful of 
intestinal parasites, and the trichina spiralis the 
encysted larvae of which lodge in the muscles. 
See Trichiniasis. 
4. Strongylidae, to which belong the Uncinaria, 
U. duodenalis (European hook-worm), U. Amer- 
icana (American hook-worm). See Hook-worm 
Disease. 
5. Ascaridae, which includes the ascaris lumbri- 
codes (the common round-worm of children) and 
the oxyuris vermicularis (pin-worm, thread-worm, 
seat-worm). 
The ascaris lumbricoides is one of the most 
common parasites affecting the human body, and 
develops in the intestines, either after the entrance 
of the ova of the same or from the so-called "in- 
termediate parasites." Their entrance is effected 
by means of food and drink. The ascaris is of 
a brown color, and has a cylindric body from 10 
to 20 inches in length and 1/8 to 1/4 inch in cir- 
cumference; the head terminates in 3 semilunar 
lips, each having about 200 teeth. The ova are 
oval-shaped, are produced in immense numbers- 
aVd 
Kggs.-{(Joplin and Bevan.) 
1$. Powdered leaves of brayera, 5 ss 
Mucilage of acacia, 
Water, 
To be taken at one dose, for an adult. 
each, 5 viij. 
The fluidextract of brayera may be given in a 
dose of 1/2 ounce to an adult. Koussin may be 
given in 40-grain doses in capsule to adults, save 
to pregnant women. 
When used alone, vermifuges should be fol- 
lowed by a full dose of castor oil, or by a saline 
purge. 
The usual remedy is santonin combined with 
calomel. The following prescription may be given 
overnight, and castor oil or citrate of magnesia or 
some saline purgative may be given the next 
morning before breakfast: 
I}. Santonin, gr. j to iij 
Calomel, gr. ss to j. WORMS 
WOUNDS 
The santonin may be dissolved in 2 or 3 tea- 
spoonfuls of castor oil and given before breakfast. 
It should not be repeated more than twice, until 
the physiologic effects have passed off. Smaller 
doses should be tried if ordinary santonin admin- 
istration causes poisoning, or compound scam- 
mony powder may be substituted. 
Whenever a round-worm is to be attacked, the 
patient should not be given solid food for from 12 
to 24 hours before, so that no residue in the intes- 
tinal canal may protect the worm. A small quan- 
tity of milk may be taken, and the anthelmintic 
should be given in the morning, after a night of 
fasting. See Anthelmintics. 
The oxyuris vermicularis develops in the large 
intestines, either from its peculiar ova or from the 
so-called "intermediate parasites," these latter 
finding their way into the 
bowel with the food and 
drink or by direct contact. 
The oxyuris resembles an 
ordinary piece of white 
thread, measuring from 
1/6 to 1/2 of an inch in 
length, the head terminat- 
ing in a mouth with three 
lips, the tail terminat- 
ing as a sharp point. The 
ova are oval, are pro- 
duced in large numbers 
-each female containing 
about 10,000-and are 
surrounded by a stout 
envelope, which increases 
their vitality. The seat- 
worm, as its name indi- 
cates, inhabits the large 
intestines, especially the 
rectum, although it fre- 
quently migrates to the 
sexual organs. The 
worms vary in number, 
sometimes the parts in- 
fested being entirely 
covered. 
Symptoms.-The oxyu- 
ris produces intense itch- 
ing about the anus, with a 
desire for stool, the pas- 
Treatment.-Santonin and calomel, with the 
use of enemata of quassia, alum, sodium chlorid, or 
phenol (5 grains to 1 pint of water) according to 
the age, the injection not to be retained; or an 
enema of a weak solution of mercuric chlorid 
(1:10,000). All medicated enemata should be pre- 
ceded by a large injection of water to unload and 
clear the rectum. Washing the anus and external 
genitals with a solution of carbolic acid should 
also be employed. For the pruritus ani a mer- 
curial ointment is useful. See Anthelmintics. 
WOUNDS.-An incised wound is a division of 
the parts, more or less extensive according to the 
extent of the injury. The fibers have only been 
simply divided; there is no contusion or laceration; 
hence they are not likely to take on severe inflam- 
mation, nor are they likely to slough or suppurate. 
By the extent and color of the hemorrhage the 
surgeon is enabled to judge of the kind of vessel 
injured: if an artery is wounded, the blood flows 
rapidly in jets and is of a florid color; if a vein, the 
bleeding is slow and the blood is of a purple color. 
Treatment.-In a recent incised wound the 
indications are to check the bleeding, to remove 
all extraneous matter, and to bring the parts in 
perfect apposition. To check the hemorrhage, 
steady, and continued pressure upon the surface 
with a sponge wet with hot corrosive sublimate 
solution will be sufficient, as a general rule. 
Should the hemorrhage proceed from a vessel of 
some size, a ligature should be applied. As soon 
as the bleeding ceases all clots are to be completely 
sponged away and all foreign bodies must be 
carefully removed; the edges are then to be brought 
together in their entire extent and retained in 
contact by means of sutures. The wound being 
dressed, the parts must be placed at rest, in a 
relaxed position. 
The wound must not be entirely closed, lest the 
secretions be retained; if this is allowed to take 
place, erysipelas may follow, and there will be 
risk of septicemia. Drainage must be provided 
for by means of drainage-tubes; they should be 
placed in the wound before it is closed, care being 
taken not to let them remain in too long. When 
the bloody serum ceases to flow, the tube must be 
removed, unless there is prolonged suppuration. 
The ligatures may be cut off short. The wound 
must be dressed antiseptically. 
Lacerated wounds are those in which the fibers, 
instead of being divided by a cutting instrument, 
have been torn asunder by violence. The edges 
of the wound are ragged and irregular; there is 
little pain or hemorrhage, and the surrounding 
parts, frequently bruised and discolored, are cold 
and numb. A lacerated wound differs from an 
incised one in the mildness of the pain and hemor- 
rhage; in its tendency to suppurate and slough; 
and in its liability to be followed by erysipelas, 
septicemia, pyemia, tetanus, and various nervous 
symptoms. When the lesion is very extensive, 
the attendant shock being necessarily severe, 
local sensation is obliterated; but when reaction 
takes place, the pain is frequently intense. 
The treatment of lacerated wounds does not 
differ greatly from that of incised wounds. All 
Oxyuris Vermicularis, to 
the left, female: to right, 
male (considerably en- 
larged). A, anus: 0, mouth: 
V, vulva.-(Braun, after 
Claus.) 
Ovum of Oxyuris 
Vermicularis. 
sages often containing much mucus, the result of 
the irritation produced by its presence. Should 
the worms migrate to the sexual organs, intense 
itching of these parts results, which in children, 
unless speedily corrected, leads to masturbation. WOUNDS 
WOUNDS 
foreign bodies must be removed, the torn vessels 
tied, and the edges of the wound gently approxi- 
mated. Guard against secondary hemorrhage by 
applying, if possible, a provisional tourniquet to 
the part, to be tightened on the slightest appear- 
ance of blood. Great care must be taken to select 
a sound portion of the artery when the ligature is 
applied. Venous hemorrhage may generally be 
controlled by a compress and roller. All tension 
is to be carefully avoided, and the edges are to be 
trimmed with scissors and the wound closed with 
sutures, using drainage-tubes if necessary. 
To moderate the inflammation, bichlorid irriga- 
tion is to be used, either warm or cold. Should 
suppuration present itself, spray the wound with 
peroxid of hydrogen, wash with corrosive subli- 
mate solution, and dress antiseptically; and when 
the granulating process is established, apply a 
solution of 3 drops of nitric acid to 1 ounce of 
water; opium cerate or dilute ointment of nitrate 
of mercury may be employed. Should the inflam- 
mation run high and gangrene threaten, purgatives 
should be used and antiphlogistic regimen ob- 
served. Anodynes, to allay pain and produce 
sleep, must be freely given. Secondary hemorrhage 
may arise as soon as reaction takes place, or it may 
occur when the sloughs begin to separate; this will 
probably take place in 5 or 6 days from the date 
of [the injury, and should be carefully guarded 
against, especially if a large artery is involved. 
Should tetanus set in, it should be promptly treated 
with anodynes, using opium, hyoscin, bromid of 
sodium, and chloral freely; blister the part, or paint 
it with tincture of iodin, or use cold bichlorid 
irrigation. See Gangrene, Sepsis, Suppuration, 
Tetanus, etc. 
Contused wounds are usually produced by 
greater violence than produces lacerated wounds, 
and are accompanied by greater disorganization; 
blood is extravasated, cellular tissue is broken 
down, muscles are bruised, and the surrounding 
parts are apt to be disorganized. They bleed but 
little in consequence of the organization of the 
parts being destroyed. The pain that accompan- 
ies a wound of this kind is in inverse ratio to the 
extent of the injury. When there is a moderate 
contusion, the pain is generally severe; and when 
there is a violent degree of contusion, the patient 
scarcely suffers any pain until reaction sets in. 
Treatment.-If there is hemorrhage, it is to be 
controlled in the usual manner-by compression, 
hot water, and ligatures. When an artery lies 
exposed in contused wounds, ligatures should 
be applied both above and below the point of 
lesion. The edges of the wound must be brought 
together gently, allowance being made for swelling 
and drainage. If it is necessary, sutures to bring 
the parts together may be used. The usual anti- 
septic dressings should be applied. When the 
inflammation is very active, leeches may be 
necessary. Pain and nervous symptoms are 
controlled by anodynes and antispasmodics. 
After the lapse of a few days, if the wound has 
healed, the part may be bathed with tincture of 
camphor, soap liniment, or dilute tincture of iodin. 
Contusions producing subcutaneous injuries 
are caused by blows from a hard, blunt object or 
by violence applied to the injured part. The 
surface is not broken, but, as a rule, blood is ex- 
tra vasated under the skin. The injury is to the 
soft parts under the skin; the connective tissue 
with its delicate vessels primarily; then the muscles 
may be crushed or torn; next the lymphatics and 
arteries; the nerves show the most resistance, 
though they may be violently stretched. 
Contusions vary in degree from a trivial bruise 
to absolute crushing of the part. In the slightest 
cases there is no perceptible bruise-mere redness 
and swelling, with local pain, which soon subsides; 
in those that are more severe there is ecchymosis, 
some of the capillaries being ruptured, and blood 
is effused into the skin or subcutaneous tissues, 
when swelling and discoloration make their 
appearance. In the worst cases the amount of 
extravasation may be enormous, as when a large 
vessel has been ruptured, or in persons in whom 
the tissue is easily torn. The scrotum or the 
loose cellular tissue of the female genitals may be 
swollen to an enormous size. The case may 
prove fatal almost at once from hemorrhage alone. 
The changes that take place in the part depend 
upon the amount of extravasation, the tension, 
the nutrition of the surrounding tissues, and the 
treatment that the injured part has received. 
Absorption is the rule; but if the tension is great, 
as when a large artery is severed, or if the part is 
not kept at rest, or if the surrounding tissues are 
not sufficiently nourished, inflammation may ensue 
when suppuration is very likely to follow. The 
degree of swelling varies with the amount and 
situation of the extravasation and with the loose- 
ness of the tissues. As a rule, the pain depends 
upon the amount of tension. In some instances 
the shock is very severe, as when the testis is 
squeezed or the abdomen is struck. If a large 
vessel is torn, the loss of blood may at once prove 
fatal. When the bruise is superficial, the staining 
of the skin will soon show itself; when deep, it 
may not appear for weeks. Traumatic fever is a 
usual accompaniment, and in cases of large extrav- 
asations may be very severe, lasting for several 
days. 
Treatment.-Slight contusions are best treated 
with cold or evaporating lotions. Lead-water and 
laudanum and acetate of lead in a decoction of 
powdered opium are especially useful. When the 
extravasation is considerable, uniform, gentle com- 
pression with many layers of cotton-wool checks 
the increase, limits the hyperemia, and promotes 
absorption. This treatment will be found effica- 
cious even when bullae are forming upon the'skin. 
The fluid should be drawn off through a minute 
puncture, and absorbed with cotton-wool or thick 
blotting paper; the epidermis should then be care- 
fully replaced and a little iodoform dusted on or 
collodion painted over, and then cotton-wool care- 
fully applied. In very severe cases when there is 
risk of suppuration, the tension may be relieved 
by the aid of the aspirator. Only a small portion 
of the fluid need be removed-sufficient to relieve 
the tension; this will at once diminish the hyper- 
emia, when absorption will proceed unchecked. WOUNDS 
WOUNDS 
The contusion is sometimes so severe as to de- 
stroy the skin. If the injury is small, and the 
deep structures are not badly implicated, the 
slough should be allowed to separate itself; but 
when the skin has been stripped off from the sub- 
cutaneous tissue to some distance above the 
apparent seat of injury, and it is thought ad- 
visable to amputate, the fine of incision must be 
carried well above, or the flaps will be sure to 
slough. 
A punctured wound is one made with a narrow- 
pointed instrument, such as needles, nails, splinters, 
swords, bayonets, scissors, hooks, etc. These 
wounds are much more dangerous than cuts or 
incised wounds, from the effects they produce on 
the injured part. 
A slight punctured wound through the skin into 
the cellular tissue will sometimes be followed by 
red lines along the course of the absorbent vessels, 
from the wound to the absorbent glands. If a 
tendinous structure is punctured, alarming symp- 
toms will frequently follow. In punctured wounds 
their depth is usually much greater than their 
width, making it frequently difficult to determine 
the amount of injury inflicted. The pain is often 
very great, depending upon the injury sustained 
by the nerves. Punctured wounds are rarely 
attended with much hemorrhage, and sometimes 
with practically none. They are very liable to be 
followed by erysipelas, lymphangitis, abscess, 
and wasting of the muscles. 
The treatment consists in the extraction of for- 
eign substances, in checking hemorrhage, in 
moderating inflammation, and in preventing the 
development of nervous symptoms. All such arti- 
cles as fish-hooks and similar barbed substances 
must be extracted by counter-openings or by 
pushing them through the part in which they 
may be embedded. If bleeding arises by reason 
of an artery having been laid open, it must be 
exposed and tied at both ends. An anodyne 
should be admininstered and the parts should be 
dressed antiseptically. Great care must be ex- 
erted to see that full and sufficient drainage is 
established. It is always safe, and frequently 
absolutely necessary, to change a punctured 
wound into an incised wound by free incisions. 
Gunshot wounds are injuries caused by sub- 
stances discharged from firearms, by fragments 
of stone or wood struck thereby, and by the 
bursting of firearms and shells. See Gunshot 
Wounds. 
Dissection wounds are those contracted in the 
examination of dead human bodies. The first 
symptom that attracts attention is a stinging or 
burning sensation; upon examining the part a 
little whitish vesicle is observed, extremely 
sensitive on pressure. When the vesicle breaks, a 
small ulcer is exposed. The pain by this time is 
very great, the sore enlarges, the swelling increases, 
and the part is hot, tense, and numb. A red line 
is usually seen, extending, from the point of in- 
oculation along the arm to the axilla. As the 
disease spreads the whole limb becomes enor- 
mously enlarged, pitting on pressure and looking 
dusky and erysipelatous. Cases occur in which 
the symptoms begin at the axilla and extend thence 
up the neck and down the side. In the worst 
forms the disease soon reaches a crisis, the system 
rapidly falling into a typhoid state. 
Treatment.-As soon as a wound of this kind is 
received, it should be thoroughly washed with 
warm water and soap; this should be followed by 
suction by the mouth. If the wound is small, 
it should be dilated; if it has bled, it should be 
thoroughly cauterized with acid nitrate of mercury, 
nitrate of silver or hydrochloric, nitric, or sulphuric 
acid. If a vesicle forms, it should be freely open- 
ed, and then thoroughly cauterized; antiseptic 
dressings should be applied, and, if necessary, 
a purgative should be administered. To relieve 
the severe pain and the restlessness, anodynes 
should be freely employed, and if the skin is hot 
and dry, aconite or veratrum viride should be 
administered. To meet the typhoid symptoms, 
milk-punch, quinin, iron, and such other treat- 
ment should be resorted to as will support and 
sustain the patient. 
Wounds of the various members, regions, and 
organs are considered under their respective head- 
ings. See Abdomen (Injuries), Neck (Injuries), 
Kidney (Injuries), etc. 
Listerian Methods of Dressing Wounds.- 
Carbolic acid was the first antiseptic, but from its 
volatility and slow'ness of action as a germicide it 
was replaced by corrosive sublimate. But this 
proved irritating, and was precipitated by the 
albumin of the blood-serum. 
What might be called the third method was the 
antiseptic dressing called serosublimate gauze, 
consisting of a gauze charged with a solution of 
corrosive sublimate in the serum of horses' blood. 
This was found difficult to manufacture, and was 
harsh and nonabsorbent. 
The fourth method consisted in a combination of 
chlorid of ammonium and bichlorid of mercury, 
called sal alembroth. This was likewise objection- 
able because of its ready solubility in the blood- 
serum. 
Fifth method, a gauze containing 3 or 4 percent 
by weight of the biniodid of mercury. This 
proved irritating to the skin. 
A sixth method consists in the employment of 
gauze impregnated with a solution of a double 
cyanid of zinc and mercury colored with a dye. 
This is said to be nonvolatile, unirritating, insolu- 
ble in water, and only soluble in 3000 parts of 
blood-serum. It possesses but little germicidal 
power, while but 1: 1200 keeps animal fluids free 
from putrefaction. 
Lister's antiseptic dressing has a base solution of 
bichlorid of mercury, 1:4000, with small quantities 
of potassium cyanid, mercuric cyanid, and zinc 
sulphate added. 
Dissolve the two cyanids in 2 ounces of distilled 
water and add the zinc sulphate dissolved in 6 
ounces of distilled water; collect the precipitate 
(which will be thrown down) upon a filter, and 
wash thoroughly by pouring over it (while still in 
the filter) distilled water. While the precipitate is 
still moist, diffuse it in 8 ounces of distilled water. 
Dissolve the hematoxylin in 1 1/2 drams of dis- WOUNDS 
tilled water, to which the ammonia has been added. 
Add this to the precipitate diffused in the water, 
allow to stand for 3 hours, then add the whole to 
the solution of bichlorid of mercury. Draw the 
gauze through this. The dye salt will settle upon 
the gauze and fix the cyanid. The gauze should 
be hung upon an antiseptic cord to drain. When 
it is nearly dry, remove and place in a tightly 
stoppered glass jar. The superfluous moisture 
can be removed by pressing the gauze between the 
layers of a sheet if needed for immediate use. 
Seventh Method.-Lister returned to the use of 
carbolic acid, preferring it to corrosive sublimate: 
(1) because it is a more powerful antiseptic; (2) 
because it has greater penetrating power. He 
combined it with the use of the double cyanid 
gauze, preparing the latter with a 1: 20 solution of 
carbolic acid. 
Antemortem and Postmortem Wounds.-A 
wound inflicted during life is generally character- 
ized by hemorrhage, coagulation of the blood, 
eversion of the edges, and retraction of its sides. 
WRY-NECK 
It may also be inferred that the wound was inflict- 
ed during life if any of the following are noticed: 
The presence of inflammation, swelling, pus, or 
gangrene on the edges of the wound, or if there is 
any sign of beginning cicatrization. 
WRIST-DROP.-See Lead (Poisoning). 
WRIST-JOINT, DISLOCATIONS.-These 
injuries are very rare, and are caused by falls on 
the hand with the hand in a very decided dorsal 
or volar flexion. Most of the cases formerly 
diagnosed as dislocation are now known to be 
typical fracture of the radial epiphysis (Colles' 
fracture). See Forearm (Fracture). 
Dislocation may be backward or forward, and 
the carpal projection and deformity will corre- 
spond. Careful palpation will determine the 
diagnosis, the similarity to fracture being the 
greatest difficulty. In both varieties traction and 
direct pressure will effect reduction. 
Dislocation of the radioulnar articulation rarely 
occurs, and is caused by twists. 
WRY-NECK.-See Torticollis. XANTHELASMA 
XEROSTOMIA 
X 
XANTHELASMA.-See Xanthoma. 
XANTHIN.-C5H4N4O2. A leukomain found in 
nearly all the tissues and liquids of the animal 
economy, and in many plants; also in minute 
quantities as a normal constituent of urine. It is 
formed, at the same time with adenin, guanin, and 
hypoxanthin, in the decomposition of nuclein by 
dilute acids. Guanin is convertible into xanthin, 
which is thought to be one step lower as an inter- 
mediate product of nuclein decomposition, and 
nearer the uric acid limit of oxidation. It prob- 
ably is oxidized in the body as fast as it is formed. 
It is a colorless powder, almost insoluble in cold 
water, but readily soluble in dilute acids and 
alkalies. It is nonpoisonous and is a muscle 
stimulant, especially of the heart. See Leuko- 
mains. 
XANTHOMA (Xanthelasma).-A form of new- 
growth of the skin, occurring as plaques embedded 
in the skin, or as nodules from the size of a pin's 
head to that of a bean, rarely larger. The color 
is yellow, usually the tint of chamois leather. The 
plaques are slightly raised above the surface, but 
are scarcely perceptible to the touch when pinched. 
They are frequently seen in the form of plates 
embedded in the eyelids, especially in persons past 
middle age who have been subject to migraine. 
X. diabeticorum (lichen diabeticorum), a rare 
disease of the skin, always associated with diabetes 
mellitus. It develops rapidly and sometimes 
intermittently; the lesions are denser and firmer 
than those of true xanthoma, and are dull red, 
discrete, and solid, though at the apex they present 
a yellowish point, like pus. They are abundant on 
the scalp and face, but never exist on the eyelids, 
nor are they ever associated with jaundice. Itch- 
ing and tingling are always present. X. lineare 
vel striatum, a form of xanthoma planum in which 
the lesions occur in lines or striae. X. maculatum 
et papulatum, a form of xanthoma planum in 
which the lesions occur in papules and macules as 
well as in plaques. X. multiplex, a form occurring 
usually in women about middle life. It is fre- 
quently hereditary, and is usually associated with 
jaundice, which, as a rule, precedes it by a year or 
more. The lesions are generally distributed. X. 
palpebrarum. See X. Planum. X. planum (xan- 
thoma palpebrarum), the commoner form of 
xanthoma, usually situated on the eyelids. X. 
tuberculatum, X. tuberosum, a rarer form of 
xanthoma, characterized by tubercular lesions 
upon the extensor surfaces of the extremities and 
on parts exposed to pressure, as the elbows and 
knees, shoulders, buttocks, backs of fingers and 
toes, and palms and soles. The lesions vary from 
the size of a hemp-seed to that of a pea, are hard 
to the touch, deeply set in the skin, and project 
prominently from it. They may coalesce and 
form veritable tumors. The disease is a chronic 
one. 
XANTHOXYLUM (Prick ly-ash).-The dried 
bark of X. americanum. It contains an acrid, 
green oil, a small quantity of tannic acid, two 
resins, and the alkaloid Xanthoxylin, which is 
probably identical with Berberin. Dose, of the 
powdered bark, 10 to 45 grains. It is a stimulant 
and aromatic bitter sialogog, diaphoretic, diuretic, 
and einmenagog. It increases cardiac actions and 
raises arterial tension. It is used in chronic 
rheumatism, myalgia, lumbago, catarrhal jaun- 
dice, dropsy, and chronic pharyngitis. Dose, of 
the fluidextract, 10 to 45 minims. 
XERODERMA (Xerosis)-A congenital dryness, 
harshness, and roughness of the skin, commonly 
appearing within the first two years of life, unac- 
companied by subjective sensations, and exhibit- 
ing to the eye a fine, scaly desquamation and a 
characteristic dull, grayish, yellowish, dirt-colored 
discoloration, chiefly involving the temples and 
the extremities. See Ichthyosis. X. of Kaposi 
a diffuse atrophy of the skin, idiopathic in origin. 
X. pigmentosum (atrophoderma pigmentosum; 
angioma pigmentosum atrophicum; melanosis 
lenticularis progressiva; Kaposi's disease), a 
very rare skin disease, beginning generally in 
summer and occurring during the second or third 
year of life. It is characterized by minute, 
measly, erythematous blotches upon parts ex- 
posed to the sun, which soon disappear, leaving 
pigment spots like ordinary freckles, which: persist 
even during winter. A spontaneous atrophy of 
the skin then occurs, resulting in the formation of 
nonpigmented, glistening scar tissue, and, finally, 
in this tissue malignant, epitheliomatous growths 
form. Death generally results about puberty. 
XEROFORM (Bismuth Tri-brom-phenol).-Is a 
patented preparation which contains about 50'per- 
cent of Bi2Os and occurs as a yellow, insoluble 
powder, having a faint odor of carbolic acid. It is 
almost nontoxic and unirritating to mucous sur- 
faces. It is an excellent surgical 'and intestinal 
antiseptic, and has been used locally with benefit in 
chancroids, buboes, foul ulcers, infected wounds, 
burns, eczema and other skin diseases. It has 
been given internally with satisfactory results in 
cholera, intestinal catarrh, and the summer diar- 
rhea of children, also for chronic urticaria and 
certain forms of infantile eczema. Dose, 7 to 15 
grains, three times a day. See Bismuth. 
XEROSTOMIA (Dry mouth).-The result of a 
diminished secretion of saliva and mucus, and is 
apparently of nervous origin. It generally occurs XEROSTOMIA 
X-RAYS 
in women over fifty years of age. The lips are 
dry and scaly, the tongue fissured like crocodile's 
skin, the cheeks and gums glazed and covered with 
crusts. The teeth are carious and slowly crumble 
away. The parotid glands become swollen and 
painful, and the skin dry and harsh. Frequently 
a similar condition is met with in the nose and con- 
junctiva. The patient, in addition to dryness of 
the mouth, complains of loss of taste, only a 
strong solution of quinin being perceived, or of 
subjective sensations as a salt flavor in the mouth. 
Treatment.-Tonics and mouth-washes with 
removal of carious stumps, and the fitting in of 
suitable dentures Sialogogs, such as pilocarpin, 
are useless, perhaps harmful. 
X-RAYS.-See Roentgen Rays. YAWS 
YELLOW FEVER 
Y 
YAWS.-Frambesia; pian; polypapilloma tropi- 
cum; amboyna button; parangi; coco; endemic 
verrugas. A tropical contagious disease of the 
skin, of long duration, characterized by dirty or 
bright red raspberry-like papules and nodules, 
tubercles, which undergo ulceration, appearing 
usually on the face, toes, and genital organs. It 
is most frequent in young colored people. It is 
believed to be caused by a slender spirochete, the 
Spirochaeta pallidula. Treatment does not differ 
materially from that of other tubercles of the skin. 
Very satisfactory results are reported from the use 
of intramuscular injections of salvarsan. 
YEASTS.-Blastomycetes or saccharomycetes 
are responsible for fermentation in many forms 
and are the cause of blastomycosis (g. v.) Cerev- 
isin, the spores of the saccharomyces cerevisise, is 
claimed to be beneficial in furunculosis. 
YELLOW FEVER.-An acute, specific in- 
fectious disease, remarkably limited in its 
geographic distribution. It is prevalent chiefly 
in tropical and semitropical regions. Upon the 
western hemisphere it occurs along the shores of 
the Gulf of Mexico and of the Caribbean Sea and in 
adjacent islands, and along the Southern Alantic 
coast of the United States, extending into the 
interior of the Southern States along railway lines 
and navigable rivers. In South America it appears 
on the Atlantic coast as far south as Montevideo 
and on the Pacific coast in Peru. In Africa it is 
limited to the west coast and contiguous islands; 
in Europe, almost exclusively to the Iberian 
peninsula. So far, the continents of Asia, Austra- 
lia, and Polynesia have been exempt. Endemic 
foci exist now principally upon the island of Cuba, 
at Rio de Janeiro, and upon the Senegambian coast. 
Yellow fever is characterized by a fever of 
sudden onset, of short duration (3 to 5 days), 
and of one paroxysm. 
Etiology.-Recent experiments carried on in Cuba 
under the auspices of the medical department of 
the United States army demonstrate the role of the 
mosquito in disseminating yellow fever infection. 
The specific organism that is the cause of this 
disease has not yet been demonstrated. The 
bacillus icteroides of Sanarelli, and the bacillus 
of Sternberg, have both been rejected. The 
Stegomyia fasciata serves as the intermediate 
host for the unknown parasite. See Mosquitos. 
The disease is not conveyed by fomites. About 
12 days or more must elapse before the contami- 
nated mosquito is capable of infecting. In the 
absence of the Stegomyia fasciata, as has been 
demonstrated, yellow fever is not contagious. 
The disease can also be transmitted by the injec- 
tion of blood taken from a yellow fever patient. 
Classification and Symptomatology.-Like most 
other acute infectious diseases, yellow fever 
occurs in different grades of severity. It is suffi- 
cient to mention the. following forms: viz., mild, 
moderate, grave, and fulminating. Conditions 
of the individual likely to aggravate the attack are 
those having a similar effect in other fevers: 
viz., loss of sleep, severe and prolonged physical 
exertion, excessive sexual indulgence, mental 
depression-as from fear, anxiety, melancholy, 
excesses in eating and drinking, and complications 
from preexisting or intercurrent diseases. Condi- 
tions favoring severity of epidemics are not fully 
understood, but unhygienic influences-as over- 
crowding, filth from decomposing vegetable and 
animal products, imperfect drainage and sewerage, 
inadequate ventilation, lack of sunlight, excessive 
heat and humidity-undoubtedly play an import- 
ant role. An epidemic moderate in the beginning 
may increase in virulence as it progresses. 
The period of incubation is usually short: most 
frequently from 1 to 5 days, and rarely exceeding 
a week. 
The onset is commonly sudden, the patient 
generally being able to state definitely the hour 
of the attack. Less frequently, the invasion is pre- 
ceded by anorexia, malaise, headache, and mental 
and muscular debility. A well-pronounced rigor 
is mentioned as an initial symptom by many 
authors, but most patients will mention only a 
sense of chilliness and discomfort. 
The fever rises rapidly, and often reaches its 
acme within a few hours from the onset. There are 
cutting pains through the forehead; the eyes ache; 
the muscles of the back, loins, thighs and calves 
are sore, and often ache severely even in mild 
cases. These symptoms continue during the febrile 
stage. It should be noted that the pains, except 
those in the head, involve the muscles rather than 
the joints. The face is turgid, not infrequently 
a dusky red; the upper lip is often swollen. 
The appearance resembles that of the early stages 
of typhus or the stage of measles before the erup- 
tion, with an addition of slight or well-marked 
jaundice. The conjunctivae are congested and 
shiny, with a yellow tinge; the eyes are sometimes 
intensely red and sensitive to light. The jaundice 
becomes more distinct after the first or second day, 
the skin showing the same combination of capil- 
lary stasis with an icteroid hue as the eyes. Yel- 
lowness may be demonstrated by pressure or 
pinching when otherwise it would be unnoticed. 
As the case progresses jaundice may be intense 
and unmistakable. 
The surface of the body may be hot and dry, 
but more frequently there is a tendency to dia- 
phoresis, whieh is especially marked at the end 
of the febrile stage. In some fatal cases the skin 
remains dry until death; in others, with the stage 
of depression there is a cold, clammy sweat. Great 
significance has been attached to a peculiar musty 
odor given off from the body; this symptom is un- YELLOW FEVER 
YELLOW FEVER 
doubtedly present in some instances, but more 
frequently it is absent. The mental condition is 
one of alertness and anxiety. 
Gastrointestinal Symptoms.-The appetite is 
lost from the beginning, but returns at the ex- 
piration of the fever. The patient is likely to be 
thirsty throughout the attack. The tongue is 
whitish in the center, with red tip and edges, and 
is pointed. The gums are swollen and are dis- 
posed to bleed easily. There is marked tenderness 
and pain in the region of the stomach; nausea and 
vomiting are very common, the vomitus in the first 
stage being chiefly the ingested fluids with mucus. 
In the stage of depression the tendency to passive 
hemorrhages is manifested by vomiting of blood 
more or less discolored and disintegrated by the 
gastric secretions; this is the black or coffee-ground 
vomit to which such grave significance is attached. 
It is often ejected with great force and in large 
quantity; at other times it may be small in amount 
and mixed with mucus, or there may be an active 
hemorrhage and vomiting of pure blood. The 
bowels are nearly always constipated; hemorrhage 
from the intestines is not infrequent, and is also 
likely to occur from the nose, gums, kidneys, and 
uterus. 
The urine is scanty; there is a decided diminution 
in the excretion of solids, and albumin is found so 
constantly as to be generally regarded as one of the 
pathognomonic symptoms. It usually appears 
within 72 hours; there may be only a trace found 
by careful testing of the evening urine. In the 
second stage, or stage of depression, the amount of 
albumin may be large, granular and other casts 
are found, and there is a decided tendency to 
suppression, with the consequent uremia. The 
early occurrence of an acute parenchymatous 
nephritis in a large proportion of cases is of the 
utmost importance, both from a diagnostic and a 
prognostic standpoint. This aspect of the sub- 
ject will receive further notice under the heading 
of differential diagnosis. 
Course of the Fever.-As previously observed, 
yellow fever is a disease of one short paroxysm, 
lasting usually from 2 to 5 days, but sometimes 
continuing longer and assuming an irregular 
or typhoid aspect. The temperature curve is 
characterized by a sudden sharp ascent, reaching 
the highest point most frequently on the first day; 
from this time the line ordinarily descends rapidly 
until the normal point is reached, which is the 
termination of the first stage. In mild cases the 
patient may rapidly become convalescent; in 
moderate or severe cases the second stage, or 
stage of depression, supervenes, when the tempera- 
ture may be normal, slightly above normal, 
subnormal, or elevated, and the fever may run an 
irregular course. It is in this stage that the serious 
effects of the toxins upon the blood and upon the 
various organs are manifested by passive hemor- 
rhages and uremia. Sternberg states that, out of 
192 cases recorded by Faget, Jones, and himself, 
the highest temperature was reached on the first 
day in 102, on the second in 54, and on the third 
in 33. The initial temperature ranges from 101.6° 
to 104.5° F. The height of the fever is an index 
to the gravity of the case. Out of 10 cases ap- 
proximating a temperature of 105° F., only 1 
recovered. The typical febrile course is likely to 
be disturbed by complications of various kinds. 
The Pulse-rate.-The pulse of yellow fever is 
characterized by its abnormal slowness and by its 
want of correlation with the temperature. This 
latter phenomenon-known as Faget's law-pos- 
sesses great diagnostic significance. It is exhibited 
best during the first 3 days. In other fevers the 
rule is that the rapidity of the pulse-rate increases 
with the temperature, while in yellow fever, though 
the thermometer may show a rise of from 1 to 4 
degrees, the pulse continues to fall. 
Diagnosis.-In order to aid physicians in the 
prompt recognition of yellow fever, and to assist 
in its prevention as far as possible, the following 
excellent presentation of the subject, made by Dr. 
Samuel L. Bemis, and adopted by the State Board 
of Health of Louisiana, is quoted. 
The following group of symptoms is considered 
to be indicative of yellow fever: 
Group First.-A person after (1) a sudden attack 
has (2) a fever of one paroxysm, attended with (3) 
marked congestion or blood stasis of capillaries of 
the surface, conjunctivae, and gums, with (4) a 
history of probable exposure to infection and (5) 
no history of a previous attack of yellow fever. 
Group Second.-A person after (1) a sudden 
attack has (2) fever of one paroxysm, followed by 
(3) unusual prostration, (4) albuminous urine, and 
(5) yellowness of the conjunctivae or skin, and 
having (6) no positively authenticated history of 
a previous attack of yellow fever. 
Group Third.-A person has (1) a fever of one 
paroxysm, (2) albuminous urine, (3) black vomit, 
(4) suppression of urine, or (5) general hemorrhagic 
tendency under (6) circumstances when exposure 
to infection is a possibility. 
The following symptoms are held to be suspicious 
of yellow fever when associated with a fever of one 
paroxysm in a person who has never had the 
disease: 
1. Suddenness of attack, either with violent 
pains in the back and head and injected eyes and 
face, or with marked congestion of the superficial 
capillaries. 
2. Want of that correlation between pulse and 
temperature usual to other forms of fever. 
3. Albuminous urine. 
4. Black vomit. 
5. General hemorrhagic tendency. 
6. Yellowness of skin. 
7. Any case respecting which reputable and 
experienced physicians disagree as to whether the 
disease is or is not yellow fever. 
8. Any case respecting which efforts are made to 
conceal its existence, full history, and true nature, 
in violation of ordinances requiring a report of the 
same. 
Differential Diagnosis.-The disease with which 
yellow fever is most likely to be confounded is 
dengue, not only from the remarkable resemblance 
of these fevers, but on account of a similar geo- 
graphic distribution and because of their frequent 
concurrent prevalence. "In time of appearance, YELLOW FEVER 
YELLOW FEVER 
and generally in geographic distribution, they seem 
related to each other. Dengue has, however, 
prevailed in Asia and Egypt, where yellow fever 
is unknown. Both diseases are arrested by 
severe frosts. Both dengue and yellow fever are 
diseases characterized by one febrile paroxysm" 
(Foster). 
In view of the possibility of dengue and yellow 
fever coexisting, the following table (from Jackson) 
is appended: 
Temperature 
Yellow Fever. 
Fever of one paroxysm, as a rule. 
High temperature for 3 days. 
Dengue. 
Fever of two paroxysms and a 
remission, as a rule. Fever 
high in first period; low in 
second. 
Malarial Fevers. 
Fever of several paroxysms 
with remissions or intermis- 
sions. Moderate temperature, 
as a rule. 
Duration of fever.. 
3 to 7 days 
5 to 8 days 
Variable duration. May last 
weeks. 
Incubation 
Human incubation, 1 to 6 days. 
Mosquito incubation about 12 days. 
Short incubation, 1 to 5 days 
average less than 3 days. 
Human incubation, 1 to several 
days. Mosquito incubation, 
about 10 days. 
Vomiting 
Very common symptom-both bil- 
ious and hemorrhagic (black vomit). 
Not common. Bilious vomit- 
ing in some cases. 
May or may not be present. 
Bilious in character. 
Pulse 
At first, rapid and bounding; later, 
abnormally slow and soft Does not 
correspond with temperature. 
Corresponds with febrile tem- 
perature. 
Corresponds with febrile tem- 
perature. 
Jaundice 
Characteristic and constant 
Rare 
Subicteric jaundice rather com- 
mon. 
Eruptions 
Rare and not characteristic 
Common and distinctive 
Rare and not characteristic. 
Urine 
Scanty; often completely suppressed, 
and albuminous from early stages. 
Quantity ample. Rarely 
albuminous. 
Not usually albuminous nor 
suppressed. 
Mentality 
Apathy common. Consciousness 
preserved as a rule. 
Preserved 
Delirium not uncommon. 
Hemorrhagic symp- 
toms. 
Frequent and often fatal. (Gastric 
and intestinal chiefly.) 
Of rare occurrence and of 
slight consequence. 
Rare except in pernicious cases 
and in malarial hemoglobin- 
uria. 
Fatality 
Average mortality 25 per cent 
Non-fatal 
Rarely fatal if treated properly. 
Convalescence 
Rapid and without sequels 
Rather prompt but with ar- 
thralgic and myalgic sequels. 
Slow, succeeded by anemia; and 
is apt to recur. 
Immunity 
One attack confers subsequent im- 
munity. 
Doubtful immunity 
No immunity. 
Response to treat- 
ment. 
Abortive or curative treatment 
negative. 
Symptomatic treatment alle- 
viates. 
Satisfactory, specific (quini e) 
treatment cures. 
Blood condition.... 
Incomplete coagulation and free 
hemoglobin in serum. Red cells 
not greatly altered. White corpus- 
cles either increased or decreased. 
Leukocytosis common. 
Decreased leukocytes claimed 
by some observers. 
Malaria parasites and pigment 
present. Leukopenia with a 
relative increase of large mono- 
nuclear leukocytes, the rule. 
The symptoms that have heretofore been relied 
upon to differentiate yellow fever and dengue are 
the occurrence in the former of albuminuria, the 
characteristic facies (inclusive of jaundice), the 
divergent pulse and temperature, and excessive 
irritability of the stomach and passive hemorrhages. 
The absence of such symptoms in the main, the 
presence of an eruption, and a want of mortality 
in connection with the ordinary febrile phenomena 
are considered as characteristic of dengue. The 
diagnostic significance of the foregoing symptoms 
requires modification: that is to say, a careful ex- 
amination of the urine in cases of undoubted 
dengue may demonstrate a mild and evanescent 
albuminuria. A certain proportion of these cases 
may have slight jaundice, severe nausea, vomiting, 
and a disposition to passive hemorrhages from 
mucous membranes. 
Aside from the increased mortality of yellow 
fever and the characteristic postmortem findings, 
the differential diagnosis between these two 
diseases can be made by the symptom-complex of 
an acute nephritis in yellow fever and its absence in 
dengue. In the latter disease simple parenchy- 
matous changes may occur in the kidneys, mani- 
fested by a slight and temporary albuminuria; 
while in the former, in a series of cases many will 
afford incontestable evidence of a severe nephritis: 
viz., scanty urine, of high color and high specific 
gravity, intense and persistent albuminuria, 
hematuria, casts, a decided tendency to suppression, 
and the accompanying uremia. There is no YELLOW FEVER 
YELLOW FEVER 
authority who will claim that a serious kidney 
involvement belongs to the pathology of dengue; 
on the contrary, it is universally conceded that the 
nephritic complications dominate the clinical 
picture in every severe case of yellow fever. 
Prognosis.-Reference has been made to the 
fact that yellow fever is a protean disease, with a 
mortality varying in the extreme degrees from 85 
percent, as in the epidemic of 1853, to 4 percent, 
as in that of 1897. Further illustrating this fact 
is the experience of Touatre, who states that in 
the epidemic of 1867 in New Orleans he lost an 
average of 1 patient in 3; in 1870, 1 in 14; in 1873, 
1 in 13; in 1878, 1 adult in 29, 1 child in 52; in 
1897 he treated 76 patients-33 adults and 43 
children-without a death. 
The death-rate will be affected: (1) By the 
comparative virulence or attenuation of the 
microorganism that produces the disease; (2) by 
idiosyncrasies, age, race, and acclimatization of 
the patients; (3) by intercurrent complications. 
The patient may be overwhelmed by the intensity 
of the toxins-suddenly struck down, with ver- 
tigo, stupor, coma, or convulsions; with weak, 
fluttering pulse; cold, clammy skin; involuntary 
discharges; and profuse hemorrhages, speedily 
terminating in death. In these fulminating cases 
the temperature is likely to be subnormal and the 
yellow discoloration of the skin is absent. 
In individual cases three important prognostic 
indications are afforded: (1) by the height and 
range of the temperature; (2) the severity of the 
kidney complications; (3) the disposition to 
hemorrhage. 
Touatre makes, the following observations: 
"When the fever reaches its maximum at the 
outset, and defervescence is continuously noted 
at each visit, the disease is mild. When the fever 
ranges between 103° and 104.5° F., even during 
the first 3 days, with remissions of at least a degree 
in the morning, and the exacerbations are less 
and less pronounced each night, the patient always 
recovers. When the fever ranges between 104° 
and 105° F., still with remissions of at least 1 
degree, but with exacerbations above the previous 
day, the disease is grave, but recoveries are more 
numerous than fatal results. When the fever 
reaches 105° F. or above within the first 12 hours, 
the attack is nearly always fatal, unless by heroic 
treatment the temperature can be reduced at 
least 2 degrees. When defervescence is not main- 
tained after the temperature has reached 105° 
F. or above, and the fever rises to the same point 
again, death is almost certain. A temperature 
above 105° F. during the first 24 hours in adults 
gives slight hopes of recovery. 
The extent of kidney involvement, and of con- 
sequent functional incapacity, is an important 
prognostic guide. The severe symptoms of the 
stage of depression, the vital prostration and the 
nausea, vomiting, headache, stupor, coma, and 
convulsions are chiefly of uremic origin. 
If the urine is abundant in spite of a decided 
albuminuria, the chances for recovery are good. 
Scanty urine, with much albumin on the 
second day, indicates danger. Recovery rarely, 
if ever, ensues after complete suppression has 
lasted as long as 12 hours. The disposition to 
passive hemorrhages, as manifested by black vomit, 
and by bleeding from the gums, intestines, uterus, 
nose, and other mucous surfaces, is of serious 
import, but is not necessarily attended by a fatal 
result. 
Prophylactic Treatment.-Yellow fever patients 
should be isolated and screened against the mos- 
quito. Nonimmunes should be guarded against 
infection by the mosquito by screening houses, etc. 
Prophylaxis consists essentially in the destruction 
of the mosquito. The stegomyia fasciata is a house 
mosquito, biting mostly by day, disliking both 
sunlight and darkness. It is often carried long 
distances by railway or ship. Tho mosquitos 
should be destroyed by drainage and insecticides. 
Breeding places should be covered with petroleum, 
etc. Disinfection of their lurking places is best 
accomplished in the house or aboard ship by means 
of fumigation with sulphur or formaldehyd. See 
Disinfection. 
Medicinal Treatment.-The important fact to be 
remembered in the treatment of yellow fever is 
that it is a self-limited disease of short duration, 
and one likely to be complicated by serious lesions 
of vital organs. There is no specific. Treatment 
should begin promptly, and while it should be 
energetic and careful, all doubtful, useless, and 
harmful medication should be avoided. 
1. The first indication is absolute rest in the 
recumbent posture from the onset until convales- 
cence is well advanced. There is no disease in 
which this rule is more imperative, or in which its 
disregard is so fraught with serious consequences. 
The action of the toxins upon the heart, kidneys, 
stomach, intestines, liver, brain, and muscular 
structures is aggravated by physical exertion. 
Hence the patient should be put to bed at once, 
should not be allowed any imprudent movements 
in bed, and should be rigidly kept there until well 
on the road to recovery. 
2. The second indication is ventilation, clean- 
liness, and disinfection of the sick-room and of all 
its appurtenances. The popular idea that fresh 
air should be excluded by closure of windows and 
doors must be combated by the physician. In the 
intensification of the infection by overcrowding 
and inadequate ventilation, yellow fever resembles 
typhus. While drafts should be avoided and 
chills from uncovering should be prevented, there 
should be an abundant admission of fresh air, and, 
if possible, of sunlight. Scrupulous cleanliness of 
bedding and clothing and of the body of the patient 
should be maintained. All excretions should be 
disinfected and speedily removed. 
3. The third indication is prompt evacuation of 
the gastrointestinal canal. If the stomach'should 
contain food at the onset, a mild emetic, such as a 
dose of ipecac or a glass of warm water with 
mustard and common salt, should be given. The 
bowels should be emptied quickly. Castor oil, on 
account of the rapidity, mildness, and certainty of 
its action, is used by many; but its nauseous odor 
and taste are objectionable to most persons, hence 
the effervescent salines are to be preferred. YELLOW FEVER 
YELLOW FEVER 
Calomel is excellent, not only for its purgative, but 
also for its antiseptic effect: from 3 to 4 grains in 
divided doses for adults, and proportionately 
smaller doses for children, is usually sufficient; it 
should be given during the first 24 hours. After- 
ward, 1 or 2 daily movements should be obtained 
by enemata of warm solutions of common salt, 
sulphate of magnesium, or sodium, to which 
glycerin, for its osmotic effect, is a useful addition. 
Purgatives are useful, not only to empty the intes- 
tines of irritant and undigested contents, but to 
prevent autoinfection, to relieve congested blood- 
vessels, to allay nausea, and to act vicariously 
on the kidneys. 
4. The hot mustard foot-bath, for its diaphoretic 
and revulsive effect. It should be given under 
blankets, and as hot as the patient can bear, hot 
water being added from time to time. Properly 
given, the foot-bath produces free action upon the 
skin, attracts the blood from the upper to the lower 
parts of the body, relieves internal congestion, and 
allays pain. 
5. Attention to Diet.-Contrary to the rule in 
treating other fevers, in yellow fever the patient 
should be starved. During the first 3 or 4 days, 
and longer in severe cases, no food whatever should 
be allowed, and then only the blandest and most 
digestible liquids, in small portions, as milk with 
lime-water, Vichy, or barley-water; buttermilk; 
wine whey; or corn, oatmeal, or barley gruel. 
Meat, eggs, beef-tea, or nitrogenous foods of any 
kind should not be given until the urine is abundant 
and free from albumin. Only those who have 
treated yellow fever can appreciate the necessity 
for such rigid rules of diet. It should be re- 
membered that digestion is in abeyance, that the 
gastrointestinal mucous membrane is intensely 
congested, that nausea and vomiting are present, 
that hemorrhage is likely to ensue, that nature 
warns us to give the stomach rest, and that food 
now is poison. Probably more patients have been 
killed by indiscreet eating during convalescence 
than by almost any other cause. The physician 
should proceed carefully, gradually increasing the 
amount and changing the character of the food as 
the symptoms indicate restoration of the functions 
of the secretory and excretory organs. 
6. Diluents, Diaphoretics, and Diuretics.-Alka- 
line carbonated waters, as Vichy or Apollinaris, 
should be freely used, and are beneficial in various 
ways: they allay nausea, correct excessive acidity, 
cleanse the stomach, and promote action of skin 
and kidneys. Ice may be added or not according 
to taste; the quantity taken may be regulated by 
the tolerance of the stomach. Warm drinks, as 
orange-leaf and watermelon-seed tea, serve a 
useful purpose in the same way, and are exten- 
sively used as domestic remedies. While it is 
important to promote activity of the skin, swelter- 
ing the patient beneath heavy blankets and ex- 
hausting him by excessive sweating should be 
prohibited. Pilocarpin, on account of its de- 
pressing effect, should be very carefully prescribed, 
if at all. Stimulating diuretics should not be 
given; it is better to flush the kidneys by the free 
use of diluents than to run the risk of increasing 
congestion by the effects of turpentine and the like. 
7. Regulation of the Temperature.-Hyper- 
pyrexia is best controlled by cold spongings and 
baths. Ordinarily, repeated spongings, as re- 
quired, with water or with a mixture of water, 
vinegar, and alcohol, at a temperature varying 
according to the height and obstinacy of the fever, 
are preferable to the cold bath; lifting the patient 
in and out of the tub, with its attendant perturba- 
tions, is objectionable. Touatre, however, is an 
earnest advocate of the cold bath in cases where 
the temperature reaches 104°-105° F. He uses 
the bath boldly, and claims that the mortality in 
such cases can be reduced in this way only. 
Opinion is divided as to the use of the coal-tar 
antipyretics; if used at all, they should be pre- 
scribed only during the first 24 hours, and then in 
moderate doses. The effects produced by these 
remedies are undoubtedly pleasant in relief of the 
symptoms; but in a disease where cardiac depres- 
sion is so marked a feature, care should be taken 
not to injure the patient for the sake of mere 
temporary relief. 
8. Treatment of Complications. Nausea, Vomit- 
ing, Black Vomit.-Direct medication to meet these 
symptoms is not usually required. In addition 
to the general measures already recommended, 
such as rest, abstention from food, iced carbonated 
drinks, purgatives, and enemata, the following 
simple procedures are advisable: sinapisms to the 
epigastrium; ice-cold cloths to head, face, and 
neck; cocain tablets in 1/4-grain doses; a combina- 
tion of creosote and subnitrate of bismuth. Rectal 
injections of chloral hydrate-from 15 to 20 grains 
for adults, and proportionately smaller doses for 
children-will not only often arrest the vomiting, 
but will allay nervous excitement and produce 
sleep. It should be remembered that the severe 
gastric symptoms are often of uremic origin, and 
that black vomit is due to profound blood and 
tissue changes, hence rational treatment should be 
directed to the underlying cause rather than to 
the symptom. 
Uremia, Albuminuria, Scanty and Suppressed 
Urine.-In addition to the general measures in- 
dicated which are, largely beneficial, in actual or 
threatened kidney trouble we must consider 
additional resources needful in the presence of these 
grave complications: viz., intravenous, intracellu- 
lar injections, or high rectal enemata of normal 
solution of chlorid of sodium in sterilized water 
and wet and dry cups over the region of the kid- 
neys. These means will sometimes succeed when 
others have failed in impending anuria. 
Restlessness and insomnia are best relieved by 
hydrated chloral administered by the rectum 
according to the necessities of the case. 
Malaria.-When the case is thus complicated, 
quinin should be given. The routine treatment 
by this agent should be condemned. 
Tendency to heart failure is to be treated by the 
moderate use of iced champagne or whisky, and by 
hypodermic injections of digitalis, strychnin, or 
caffein. 
A nurse who will carry out the physician's in- 
structions to the letter is indispensable. Many YELLOW FEVER 
YERBA SANTA 
patients with yellow fever are frightened to death. 
The conduct of attendants should be such as to 
quiet fear and excitement, instead of contributing 
to them. It is only by careful attention to details 
that success may be attained in severe cases. If 
possible, there should be an attendant who has 
had previous experience with the disease. 
Sternberg's treatment, by means of which a 
death rate of only 7.3 percent was secured, con- 
sists in giving 7 1/2 grains of sodium bicarbonate 
and 1/60 grain of bichlorid of mercury every hour 
with a liberal amount of water. In addition, a 
hot mustard foot-bath is advised during the first 
day, no food being given for 3 days, and then 
stimulants and a milk diet are ordered. Cold 
sponging and cold applications to the head and 
sinapisms over the stomach and lumbar regions 
are recommended. 
Serum treatment has not yet proved satisfactory. 
YEO'S METHOD.-A method of treating 
obesity, consisting of a dietary that limits the 
amount of farinaceous food, prohibits sugar, limits 
the amount of liquids taken with the meals, but 
encourages the drinking of large amounts of hot or 
warm aromatic beverages between meals. 
YERBA SANTA.-See Ekiodictyon. ZEA 
ZOSTER 
z 
ZEA (Corn Silk; Maize; Indian Corn).-The 
fresh styles and stigmas of Zea Mays, the maize or 
Indian corn. It contains maizenic acid, a fixed 
oil, resins and salts. Dose, of a fluidextract, 1 to 2 
drams; of an infusion (1 to 8), 4 to 8 ounces, almost 
ad libitum. There are no official preparations. 
Zea is a certain but mild diuretic when given in 
full doses at short intervals. It has been used 
with success for incontinence of urine, uric and 
phosphatic gravel, gout, rheumatism, urethritis, 
pyelitis, acute and chronic cystitis, cardiac 
dropsy and obstructive valvular disease of the 
heart. 
ZINC (Zincum). Zn = 64.9; quantivalence n.-A 
metallic element, with a lead-like luster. It is 
represented in medicine by several of its salts, all 
of which are more or less poisonous. In small 
doses it is tonic and astringent; in larger quantities, 
a strong emetic. It is used mainly in the form 
of lotions in conjunctivitis, in various catarrhs, 
and in certain skin-diseases. 
Preparations.-Z. Acetas, soluble in 3 of water 
and in 36 of alcohol at 59° F., in 1/2 of boiling water 
and in 3 of boiling alcohol. Used locally as an 
astringent in solution of 1 or 2 grains to the ounce, 
or internally in doses of 1/2 to 3 grains. Z. 
Carbonas Praecipitatus, insoluble in water or alco- 
hol, but soluble in acids with copious effervescence. 
Used locally as a protective. Z. Chloridum, very 
soluble in water and in alcohol; very deliquescent. 
Is tonic and escharotic. For internal use a solu- 
tion in spirit of ether is the most convenient form, 
strength 1 dram to the ounce, of which 4 to 8 min- 
ims may be given twice daily in water. Strength 
of injections and colly ria, 1 to 2 grains to the 
ounce. Liquor Z. Chloridi is an aqueous solution, 
containing about 50 percent of the salt. A clear, 
colorless, odorless liquid, of a very astringent, 
sweetish taste and an acid reaction. A powerful 
disinfectant for sinks, drains, etc. Used also as an 
injection in gonorrhea, leukorrhea, etc., in dilute 
solution, 1/2 to 1 percent. Burnett's Disinfecting 
Fluid is similar to the above, but slightly stronger. 
Z. lodidum, very soluble in water and in alcohol. 
Dose, 1/2 to 2 grains in syrup. Z. Oxidum, in- 
soluble in water or alcohol; soluble without effer- 
vescence in dilute acids; also in ammonia water. 
Dose, 1 to 10 grains in pill. Unguentum Z. Oxidi 
has of zinc oxid 20, benzoinated lard 80. Z. 
Phenolsulphonas (Zinc Sulphocarbolate'), very sol- 
uble in water and in alcohol. Dose, 1 to 5 grains. 
Z. Stearas. Used locally as a dressing powder and 
a vehicle for dry antiseptics. Unguentum Z. 
Stearatis, strength 50 percent, made with white 
petrolatum. Z. Sulphas, soluble in 0.6 of water, 
insoluble in alcohol. Dose, as emetic, 10 to 20 
grains; as a tonic and astringent, 1/10 to 2 grains 
in pill. Z. Valeras, soluble in about 50 of water 
and in about 35 of alcohol. Dose, 1 /4 to 4 grains 
in pill. 
ZINGIBER.-See Ginger. 
ZOSTER.-See Herpes Zoster.